Art Therapy and Anger

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Art Therapy and Anger

by the same author Arts Approaches to Conflict Edited by Marian Liebmann ISBN 978 1 85302 293 7

Art Therapy with Offenders Edited by Marian Liebmann Foreword by Judge Stephen Tumim ISBN 978 1 85302 171 8

Restorative Justice How it Works

Marian Liebmann ISBN 978 1 84310 074 4

Mediation in Context Edited by Marian Liebmann ISBN 978 1 85302 618 8

Art Therapy in Practice Edited by Marian Liebmann ISBN 978 1 85302 058 2

Art Therapy, Race and Culture Edited by Jean Campbell, Marian Liebmann, Frederica Brooks, Jenny Jones and Cathy Ward Foreword by Suman Fernando ISBN 978 1 85302 578 5

Art Therapy and Anger Edited by Marian Liebmann

Jessica Kingsley Publishers London and Philadelphia

First published in 2008 by Jessica Kingsley Publishers 116 Pentonville Road London N1 9JB, UK and 400 Market Street, Suite 400 Philadelphia, PA 19106, USA www.jkp.com Copyright © Jessica Kingsley Publishers 2008 All rights reserved. No part of this publication may be reproduced in any material form (including photocopying or storing it in any medium by electronic means and whether or not transiently or incidentally to some other use of this publication) without the written permission of the copyright owner except in accordance with the provisions of the Copyright, Designs and Patents Act 1988 or under the terms of a licence issued by the Copyright Licensing Agency Ltd, Saffron House, 6–10 Kirby Street, London EC1N 8TS. Applications for the copyright owner’s written permission to reproduce any part of this publication should be addressed to the publisher. Warning: The doing of an unauthorised act in relation to a copyright work may result in both a civil claim for damages and criminal prosecution. Library of Congress Cataloging in Publication Data Art therapy and anger / edited by Marian Liebmann. p. ; cm. Includes bibliographical references and index. ISBN 978-1-84310-425-4 (pb : alk. paper) 1. Anger. 2. Art therapy. I. Liebmann, Marian, 1942[DNLM: 1. Art Therapy--methods. 2. Anger. 3. Professional-Patient Relations. WM 450.5.A8 A783865 2008] RC569.5.A53A78 2008 616.89'1656--dc22 2008000826

British Library Cataloguing in Publication Data A CIP catalogue record for this book is available from the British Library

ISBN 978 1 84310 425 4 ISBN pdf eBook 978 1 84642 810 4

Printed and bound in Great Britain by Athenaeum Press, Gateshead, Tyne and Wear

Contents LIST OF FIGURES

7

INTRODUCTION

9

Marian Liebmann

Part I: Children 1.

The Anger of Abused Children

27

Maggie Ambridge, Vulnerable Children’s Service, Child and Adolescent Mental Health Service

2.

Anger Management with Children and Young People: Creative Tools to Mend Broken Tempers

42

Leila Moules, Crewe Child and Adolescent Mental Health Service

3.

When Love is Absent, Anger Fills the Void: Children in Foster Care

58

Elaine Holliday, Principal Therapist, Foster Care Associates

4.

Anger and Danger: Adolescents and Self-harm

72

Sheila Knight, Bassetlaw Child and Family Therapy Service, Nottinghamshire

Part II: Offenders 5.

Inside-Out/Outside-In: Art Therapy with Young Male Offenders in Prison

87

Sue Pittam, Young Offender Institution, UK

6.

Androcles and the Lion: Prolific Offenders on Probation

102

Hannah Godfrey, National Probation Service

7.

What Anger? Working with Acting-out Behaviour in a Secure Setting Kate Rothwell, University of Hertfordshire

117

8.

Avoided Anger: Art and Music Therapy in a Mediumsecure Setting

134

Simon Hastilow and Terri Coyle, South West London and St George’s Mental Health NHS Trust

Part III: Mental Health 9.

The Role of Anger in Women who Cope by Self-harming

151

Camilla Hall, Coventry and Warwickshire Primary Care Trust

10.

Art Therapy with Cognitive Behavioural Therapy in Adult Mental Health

166

Susan Law, Priory Hospital, Hayes, Kent

11.

Working on Anger Issues with a Deaf Client

180

Marian Liebmann, Bristol Inner City Support and Recovery Team

Part IV: Other Client Groups 12.

Angry Mothers

197

Susan Hogan, University of Derby

13.

Art Therapy and Anger after Brain Injury

211

Sally Weston, Neurological Rehabilitation Unit (NHS) Sheffield

14.

Not Being Calm: Art Therapy and Cancer

226

Hilary Brosh, Robert Ogden Macmillan Centre

15.

‘Came Back – Didn’t Come Home’: Returning from a War Zone

238

Annette Coulter, Centre for Art Psychotherapy, Wentworth Falls, Blue Mountain, New South Wales, Australia APPENDIX

257

LIST OF CONTRIBUTORS

258

SUBJECT INDEX

261

AUTHOR INDEX

267

List of Figures 1.1 1.2 1.3 1.4 2.1 2.2 2.3 2.4 3.1 3.2 3.3 3.4 4.1 4.2 4.3 4.4 4.5 5.1 5.2 5.3 5.4 6.1 6.2 7.1 7.2 7.3 7.4 7.5 7.6 8.1 8.2 9.1 9.2 9.3 9.4 9.5 10.1 10.2 10.3

Billy: A man looking into a mirror Eliza: The naughty monkey Jamie’s first drawing Jamie’s second drawing Anger diary Anger rating scale Liam: Naughty and good sides Simon: Body outline drawing The paper island One of several volcanoes made by Karl King Kong The empty basket Anger – Keep Out Jules: Pattern James: A car James: My dad James: Me Art therapy initial evaluation form Dan: Stormy sea Dan: Buildings on fire Sean: Rhinoceros head (left) and whole rhinoceros encased in duck (right) Jason: Two clay elephants and their keeper Jason: Red and black mask Heather: Doodle (detail) Philip: Self-portrait as a devil Philip: Tank Philip: ‘Expressing myself ’ Philip: Swastika Philip: Landscape Toby: Picture 1 Toby: Picture 2 Maureen: Moving towards the light Sam: Diagrammatic expression Sam: The bomb Coffin with boxing gloves Sam: Petticoat over black hole S: Relationship with himself D: Looking at himself in a mirror M: Himself and partner

29 35 38 39 48 49 54 55 62 64 65 68 74 80 82 82 82 92 94 95 97 111 113 123 126 127 128 129 131 140 144 156 160 161 162 163 172 173 173

10.4 10.5 11.1 11.2 11.3 11.4 12.1

A: Self-box D: On a pedestal with family looking up to him Introductory picture Physical symptoms of anger A peaceful place Family patterns: isolation Jay described her episiotomy as a ‘kind of rape’ (Photo by Suzanne Calomeris) 13.1 ‘Oh my God! They killed Kenny!’ 13.2 zzzz: disaster waiting to happen 13.3 Stress – can this game be won? 13.4 Invincible 13.5 Back to normal? 15.1 Vietnam 15.2 Visual diary: Nine lives 15.3 Untitled 15.4 Insignificance magnified 15.5 Metamorphosis 15.6 Vitality 15.7 Came Back – Didn’t Come Home? 15.8 Anger 15.9 Punish me 15.10 Getting help 15.11 Dragon (from ‘Dragon Series’)

176 177 186 187 188 191 199 217 219 220 222 223 241 244 246 247 248 249 250 251 252 253 254

Introduction Marian Liebmann

This book is called ‘Art Therapy and Anger’ rather than ‘Art Therapy and Anger Management’ because there are a variety of views about anger and whether it is a destructive emotion to be ‘managed’ or a constructive emotion to be welcomed and expressed. This diversity of views will be apparent in the chapters in the book.

Personal journey I grew up at a time when girls were encouraged to suppress their emotions, especially anger – it was not ‘ladylike’. So when as an adult I became interested in therapy, the idea that anger should be expressed was an appealing one that helped me to see my anger as a positive emotion. ‘Let it all hang out’ was an encouragement from the 1960s. However, when I later started working with offenders, I was stopped in my tracks: here were people who had no difficulty in ‘letting it out’ – all over other people, causing untold damage to them, and sometimes to themselves in terms of ruined relationships. I needed to think again. Whilst working for the Probation Service, I had the opportunity to join in with the programme of anger management groups for violent offenders. These were run on cognitive behavioural therapy (CBT) lines, which had been researched by others as the most effective methodology with offenders. It was hard work, but these groups did seem to achieve results when the participants grudgingly tried out the techniques. For many of them, attending the group was a turning point in their pattern of violent offending, and they began to see that there were other ways of dealing with conflict. When I moved to work in the mental health service, there were still plenty of angry clients (some of them offenders as well as mental health clients). I adapted the CBT framework into a themed art therapy group (with 9

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some additions), with CBT and other handouts alongside the group for those who found them useful. A co-facilitator who had run CBT groups in a regional secure unit said the art therapy groups provided a much deeper and richer experience than the verbal groups. Another piece of learning came from running these groups. The first one started as a mixed group, but two of the women dropped out for domestic reasons, and the other two gave up because they felt outnumbered. However, the same happened with the next group – was this a pattern? I managed to contact one of the women, who said the group was ‘too macho’ in its preoccupations and ‘the men took up too much air space’. We managed to rectify this somewhat, and she returned. But I thought it would be good to run a ‘women only’ anger management group. This was a small group of four women but it ran well – and all four chose to disclose their experience of sexual abuse in the third session. Here was the reason for the previous groups ending up as ‘all men’ groups – the women said they would not be able to talk about their abuse issues in a mixed group. By this time I was beginning to be fascinated by the whole topic of anger. I also have my own reservoir of angry feelings to draw on, and I have found certain techniques extremely helpful. There seem to be so many angry people around now – is this because there are more things to make us angry, or because it is all right to talk about it, or because it is seen as a problem we can do something about? A trawl of books on anger available through the Amazon website resulted in over 1000 results. I printed off the first 90 and stopped, overwhelmed; there was little overlap between the titles – these were almost all different titles on the same subject. I wanted to know more about how other art therapists viewed anger and helped clients to deal with their angry feelings. What better way than putting together an edited book on the subject, which may then also be of use to others? It has been an interesting journey. For many books I have worked on, I have had to work really hard to find contributors – for this one, as soon as the word was out (via the British Association of Art Therapists’ newsletter), about 35 contributions came hurtling through the e-mail. It was sad to have to turn down many worthwhile offers, but I hope the ones in the book will be of interest and of practical use.

Different views of anger To write this introduction I tried to read a selection of books on anger, thinking I might arrive at a general consensus of the ‘best’ way to look at this

INTRODUCTION

11

slippery emotion. But the more I read, the more ideas made themselves known – it has been impossible (within the limits of my time) to reach a definite conclusion. So what I have included here is a ‘sample’ of views and ideas. No doubt further reading would elicit more. To counter what seems like a rising tide of unmanageable anger in children and adults, there is now a plethora of anger management manuals. They tend to include things such as: ·

exploration of what anger means to people

·

anger diaries

·

challenging perceptions

·

awareness of physical symptoms

·

relaxation techniques

·

assertiveness

·

positive self-talk.

Carol Tavris (1989, p.93), in her excellent book Anger: The Misunderstood Emotion, points out that anger has a cultural element – its occurrence and acceptable expression vary in different societies. It involves the mind, the body and behavioural habits built up over years to cope with emotional stress. So to be successful, anger management programmes need to include three elements (Tavris 1989, p.288): ·

The mind: helping people to identify the perceptions and interpretations that generate anger.

·

The body: teaching relaxation and cooling-down techniques to help people to calm down so that they can think about things (when people are at the height of their anger, they are so aroused that they cannot think at all).

·

Behaviour: teaching new skills, such as assertiveness.

Each programme has its particular emphasis. One of the earliest cognitive behavioural programmes used widely around the world was pioneered by Novaco (Novaco 1975; Novaco, Ramm and Black 2000). Another wellknown programme for violent offenders, the Aggression Replacement Training (ART) programme, uses a multi-modal approach working on the aspects mentioned above, combined with a moral reasoning element to give

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some input on why offenders should change their behaviour (Goldstein and Glick 1987). Many books distinguish between clean and unclean or dirty anger, or healthy and unhealthy anger (Dryden 1996; Fisher 2005; Whitehouse and Pudney 1996), recognising that anger has a positive aspect in alerting us to the fact that something is not OK for us and needs putting right. A Buddhist view also values anger as ‘a friend to be embraced’ and worked with, rather than suppressed (Hanh 2001). Tavris (1989) emphasises that one of the main ways of reducing anger is actually doing something about the problem causing the anger. She also points out that anger is often the starting point for taking action against injustice. People with chronic anger problems may need more help than simple anger management techniques. Their anger often has roots in childhood abuse and deprivation. Sue Gerhardt (2004) shows how babies who are treated harshly or lack attachment may not develop empathy for others, and grow up with a reservoir of anger against the world. Harriet Lerner (2004) describes ways of linking anger in families to early family dynamics. Mike Fisher (2005) has a chapter on facing past traumas. Often poor self-esteem is involved. Certainly, people in groups that I have run have identified events in the past which have left them with immense anger. To some extent therapy and good later relationships can help with this. So anger is a complex emotion, and therefore needs a complex response. Art therapy involves doing, thinking and feeling, as well as talking, so it may have something particular to offer.

Different ways of working with anger: a local survey To help me learn more about working with anger in practice, I interviewed 19 local therapists and facilitators working with clients who have anger problems or issues. I found these people via colleagues, local associations and advertisements for anger management courses. They included therapists, teachers, a Parentline Plus facilitator, youth facilitators and mediators. Again, I hoped to find a consensus of opinion but did not. I talked to many experienced practitioners, all working successfully with anger – in very different ways. Theoretical starting points included: ·

Jung’s work on ‘the shadow’ side of human beings

·

Process-oriented psychology

INTRODUCTION ·

Fire analogy

·

Cognitive approaches

·

Gestalt work

·

Brief and solution-focused therapy

·

Family therapy

·

Self-esteem approaches

·

Buddhist approaches

·

Other spiritual approaches

·

Psycho-educational approaches

·

Psychodynamic approaches

·

Psychodrama and sociodrama

·

Psychosynthesis

·

Neuro-linguistic programming (NLP)

·

Hypnotherapy.

13

Several therapists emphasised the importance of working out the meaning of anger, seeing it as a valuable warning sign that things are not all right, and need attention. Some therapists keep to the ‘here and now’, while others find it important to make links with the past to enhance understanding. Although a few valued ‘cushion-bashing’ as a release, most felt a more psychological approach was of greater value. The psycho-educational approach usually includes exercises looking at different aspects of anger as it is experienced, while those using a solution-focused approach only look at the ways in which people manage their anger successfully and help them to build on this. To do justice to the breadth and depth of work shared with me would take another book. I am grateful for the opportunity to enhance my awareness of the variety of work being done with anger. I have acknowledged all those I interviewed at the end of this Introduction.

Art therapy with anger It is part of all art therapists’ practice to deal with anger as one of the many emotions that may be expressed by clients, and there are references to work with anger in many art therapy books and articles. But there are few books or

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articles which focus on work with anger. Books on art therapy with offenders, with people in conflict and in social action projects include more work on anger (Kaplan 2007; Liebmann 1994, 1996) and there are some American journal articles on research into different aspects of art therapy with anger (see the Appendix). The diversity of practice noted in the survey above is also true of the contributors to this book. Art therapists (or art psychotherapists) differ in their theoretical orientation and in their practice. Many work from a psychodynamic perspective but there are also art therapists working in humanistic and cognitive ways. However, the use of art materials brings all the contributors together and makes a huge difference in working with anger. Art therapy has several particular things to offer in work on anger management. ·

It provides another way to communicate for people who find it hard to articulate verbally why they get angry.

·

The process of doing the artwork slows clients down and helps them to reflect more on what is going on.

·

Using art can be a less threatening way to approach issues.

·

Neurological research suggests that art therapy can help different parts of the brain to communicate, linking creative processes with language and long-term memory. This can then facilitate the ability to use cognitive skills to learn (see Chapter 5 for further details).

·

The boundaries of the art therapy session, using art materials in a contained way, provides a feeling of safety in which clients can begin to look at their anger without getting out of control.

·

Using art provides the possibility of including many thoughts and feelings, often contradictory, on one page. This can then help clients to look at these and develop an ‘observer self’ (see Chapter 9).

·

There is no ‘right’ or ‘wrong’ way of doing art, so it provides a relief from the pressures of goal-oriented therapies.

·

In group work, sharing the artwork helps people realise that they have things in common with each other, thereby overcoming isolation.

INTRODUCTION ·

15

In group work, doing artwork enables a group to include both those who ‘act out’ their anger on others and those who ‘act in’ their anger on themselves. (In a verbal group it is often difficult to include these in the same group.)

Risk assessment As with other therapies, several art therapists make the point that a client has to be willing and ready to do this work – Chapter 6 provides an example of an angry man who felt that even to discuss the subject was likely to lead to uncontrollable rage, whereas Chapter 2 discusses how to assess children’s willingness and readiness.

Multidisciplinary work Almost all the art therapists in this book work in multidisciplinary settings, where liaison with other professionals is paramount. This is also very relevant to working with anger, as there is a real danger of escalating the very problems being addressed, if there are conflicting approaches within the team.

Diversity issues involving anger Using art materials is helpful in working with people with disabilities, who often struggle to express themselves in verbal language. Examples in this book include children and adults with learning difficulties (see Chapters 1, 2 and 8), Deaf people (see Chapter 11) and people with brain injury (see Chapter 13). In contexts where there are people of different races or cultures, anger can often arise from different interpretations of situations, even of colours used. Art materials can be used to work on these issues (see Chapter 7).

Gender issues In general most of the chapters follow the stereotypical ‘division of labour’ in expression of anger, with therapy being provided for boys and men who act out, and girls and women who self-harm. But this is not always the case: there are instances of boys and men who self-harm (see Chapters 5, 8, 11 and 15) and girls and women who act out (see Chapters 1, 7, 9 and 13). Many clients do both. Tavris (1989, p.215) argues that the stereotypical difference

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in expression is more due to differences in status between men and women than any inherent differences in feelings.

Directive and non-directive methods There is controversy in the art therapy world over whether directive or non-directive work is ‘best’, with firm views held by many. In this book most art therapists use a non-directive approach, but a few use a directive approach (see Chapters 10 and 11). Some art therapists use a mixture, according to the needs of clients or situations (see Chapters 1, 14 and 15). The relationship formed between art therapist and client is always the most important factor.

Materials used This book includes examples of many different art media, which can all be used to express different aspects of anger. Sometimes materials like clay and thick paint lend themselves to the more cathartic and expressive uses (for example, Chapters 1, 3, 5 and 9), while finer materials lend themselves more to symbolic expression and reflective work. However, the most important thing is to follow clients’ choice of media and help them use it to express what is important to them.

Different ways art therapy may be used with anger The art therapists in this book have used ways of working which may fall under a number of headings. To arrive at these headings, I went through each chapter to note the different ways in which art therapy was used, and gradually built up the system of classification – it grew from the chapters rather than being imported from elsewhere and superimposed.

Catharsis Children often use the art materials to act out anger, in ways such as pounding clay or making a mess with paint and other materials, maybe squashing paper and trashing it. It can also include more specific acting out, such as making models from clay or junk materials which are then stabbed, decapitated or torn limb from limb (see Chapter 1). Adults can also engage in this, by depicting violence in pictures in a threatening way, or using symbols such as a swastika (see Chapter 7), or attacking a clay figure and scribbling over drawings (see Chapter 9) or combining art with self-harm using blood

INTRODUCTION

17

(see Chapter 15). Catharsis of this kind can be seen as less damaging than a verbal or physical attack on others, and a bridge to a more symbolic use of art, in which reflection can take place.

Expressing anger in a symbolic way This is probably the heart of the use of art therapy with anger. It involves expressing feelings through drawing or clay work, and symbolic play with objects, trying to make sense of angry feelings, often using the art work as a bridge to being able to talk about these. Often objects such as volcanoes, bombs, storms and fires play a part here, as they can symbolise anger overflowing or taking over in an uncontrolled and frightening way (see Chapters 1, 2, 3, 4, 5, 7, 9, 10, 12, 13, 14 and 15). Writing poems can also be used in this way (see Chapters 4 and 15). Sometimes anger is crystallised in a symbol which resolves good and bad aspects of anger in one image, such as the dragon in Chapter 15 and on the cover of this book.

Metaphors for anger Sometimes visual metaphors or stories may be used as ways in to developing a vocabulary for talking about anger. Examples of these are the photo of a signpost connecting ‘Anger and Danger’ (Chapter 4), where danger is removed when anger is acknowledged, and the story of ‘Androcles and the Lion’ (Chapter 6), where the process of dealing with the anger is compared to drawing out the painful thorn from the lion’s paw. Another metaphor of ‘dry interconnecting cogs causing friction’ is described in Chapter 9.

Expressing feelings that mask anger Often there are many feelings and actions masking anger, such as depression, self-harm and poor self-esteem. These can be expressed using art materials, leading to a realisation of underlying anger, which can then be acknowledged and worked with (see Chapters 4, 5, 8, 12 and 14). Anger is sometimes completely denied (see Chapters 6, 7 and 8) or displaced on to other people (see Chapters 13 and 14). Masks can be decorated and used to ‘try on’ different feelings, including anger. Clients can then try to reintegrate these feelings (see Chapter 6).

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Expressing feelings behind anger Many people with serious anger issues have suffered deprivation, abuse or abandonment in childhood (see above), and use their anger and rage to cover up or avoid deep hurt and loss. Sometimes this anger is displaced on to others, often those close to them. These feelings can be expressed through art, if the setting is safe enough for people to do so (see Chapters 3, 9, 10, 11 and 13).

Exercises to look at anger These involve visual methods to look at anger, like the rating scale in the form of a flight of stairs (see Chapter 2), drawing physical symptoms (see Chapters 2 and 11) and visual diaries (see Chapters 2 and 15). These sometimes have a base in CBT but benefit from being expressed in visual form. They help to develop a vocabulary for discussing anger issues (see Chapters 2 and 4). In some cases, art therapy forms part of a larger programme of work on anger, including CBT and other exercises: in these contexts art therapy provides an opportunity for participants to reflect non-verbally on the issues raised. This can be done non-directively (see Chapter 9) or directively (see Chapter 10).

Exercises to control anger In the programmes where art therapy is part of a larger programme, such exercises are usually included in the verbal or CBT section of the course, and the role of art therapy is to provide an opportunity for wider reflection, as above (see Chapters 9, 10 and 13). These often include a variety of relaxation and visualisation techniques, which draw on visual capabilities and promote communication between different parts of the brain. These can be enhanced by using art materials (see Chapters 2 and 11).

Replacing anger by creativity Sometimes when anger subsides there is a vacuum. Then the art materials can be used to develop creativity and self-esteem, and to try out tentative steps of a different way of being, sometimes discovering strengths and possibilities not previously thought possible (see Chapters 3, 4, 5, 12, 13, 14 and 15).

INTRODUCTION

19

Summary of chapters in this book Chapter 1: The Anger of Abused Children This chapter focuses on the way that sexual and physical abuse of children leads to anger that they often visit on non-abusing parents and on others around them, particularly if children are not able to verbalise what has happened to them. The author shows how art therapy can help children find their voice and express their anger more appropriately through symbolic means. The case studies cover a boy over a long period from age 8 to 17 years, a girl of 12 with learning difficulties and a very young child aged three.

Chapter 2: Anger Management with Children and Young People: Creative Tools to Mend Broken Tempers In this chapter, the author describes how a child and adolescent mental health service (CAMHS) works with children and young people who have outbursts of uncontrollable anger, and with their families, too. The chapter includes a ‘toolbox’ of techniques which may be helpful, including an anger diary, an anger rating scale, relaxation techniques and ‘angry words’ to develop vocabulary around anger. These are interwoven with art therapy methods to help the child develop ways of expressing feelings in a less damaging way, and are illustrated by two case studies and two further vignettes.

Chapter 3: When Love is Absent, Anger Fills the Void: Children in Foster Care This chapter discusses the complexity of working with children in foster care, where many professionals and agencies are involved. It uses a case study of a 12-year-old boy to show how issues of anger need a whole-team approach to resolve. The role of art therapy in providing an expressive outlet for the anger, and alerting the team to wider issues, is explored. Art therapy is also valuable in exploring the gap left when anger subsides, and in providing a long-term creative therapy over a period of time.

Chapter 4: Anger and Danger: Adolescents and Self-harm This chapter draws on the imagery of a notice by a river saying ‘DANGER – KEEP OUT’ which had been altered to ‘ANGER – KEEP OUT’. This

20

ART THERAPY AND ANGER

analogy is used to describe ‘dangerous’ situations of self-harm in adolescent mental health, where the danger can be removed, leaving anger as a positive emotion that needs to be heard. This process is illustrated by three case studies, including pictures and poems by adolescents, and one case study of a father and son.

Chapter 5: Inside-Out/Outside-In: Art Therapy with Young Male Offenders in Prison This chapter describes how art therapy works at one young offender institution, and the way art therapy can help young offenders who display outward anger and those who bottle anger up inside them. The two case studies show an example of each, and the connection between their anger and the abuse they had suffered. Recent research in the neurophysiology of the brain is described, showing how art therapy can be of particular help in these situations.

Chapter 6: Androcles and the Lion: Prolific Offenders on Probation This chapter describes individual art therapy work with prolific offenders on probation, using the fable of ‘Androcles and the Lion’ as a metaphor for removing the ‘thorn of anger’ from clients, and the delicate way this needs to be done. Two case studies show different aspects of the work: the first describes an assessment of a violent offender who was not ready to give up his anger and was unsafe to work with; the second describes the way art therapy was used to help a client explore his family dynamics and become aware of the anger which lay behind his offending.

Chapter 7: What Anger? Working with Acting-out Behaviour in a Secure Setting This chapter looks at the way anger can be processed through art therapy in a women’s prison and in a medium-secure mental health setting. An incident in the women’s prison is described, where anger at race issues was defused by an art therapy session. Work with a dangerous woman prisoner shows how the anger may be shown in a disguised way through the art work. A case study of a violent and racist man in a medium-secure unit shows how art therapy helped him over a period of time to think about (rather than act out) his anger towards others.

INTRODUCTION

21

Chapter 8: Avoided Anger: Art and Music Therapy in a Medium-secure Setting This chapter looks at the way art therapy and music therapy are used in parallel with someone who expressed anger through arson. It also looks at the changes in the use of these before and after a decision to transfer the client to a long-term unit, and the way the therapies could be used to facilitate endings safely.

Both Chapters 7 and 8 show how anger is often avoided in custodial institutions, but is ever-present and in danger of erupting. In Chapter 7 the anger was suppressed by the institution, while in Chapter 8 the anger had been suppressed by the client from an early age. In both cases arts therapies helped to facilitate and work with these feelings in a safe and contained way.

Chapter 9: The Role of Anger in Women who Cope by Self-harming This chapter describes an art therapy group for women who cope by self-harming, alongside a psycho-educational programme. It looks at the role that anger played in the group – at times destructive, at times cathartic. It describes the anger of two women who had been abused, and their effect on the rest of the group.

Chapter 10: Art Therapy with Cognitive Behavioural Therapy in Adult Mental Health This chapter describes an eight-session art therapy group which is run in parallel with a cognitive behavioural therapy (CBT) group, for outpatients to look at ‘difficult emotions’ (mainly anger). The art therapy group adds another dimension to participants’ learning and development. The chapter describes the journeys through this group made by five participants, and the ways they were able to use the groups to make changes in their lives.

Chapter 11: Working on Anger Issues with a Deaf Client This chapter describes a short-term piece of work with a deaf client who had mental health issues and a problem with anger. The work took place through a British Sign Language (BSL) interpreter, and included a mixture of art therapy and cognitive behavioural techniques. The art therapy led to an

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important realisation and turning point for the client, and the cognitive behavioural techniques gave him the skills to make use of this in his daily life.

Chapter 12: Angry Mothers This chapter describes the use of art therapy groups as a support for pregnant women and new mothers. The physical shock of birth and the sometimes unwanted medical interventions, especially if the birth is difficult, can lead to anger and a sense of betrayal. Along with this, there can be a sense of powerlessness and lack of control, which can also fuel the anger. Exhaustion can exacerbate these effects. The art therapy groups provided an opportunity for the women to express these feelings, and to explore their changed sense of self-identity as a result of pregnancy and motherhood.

Chapter 13: Art Therapy and Anger after Brain Injury This chapter describes how brain injury can often lead to feelings of anger. This can sometimes be caused by the actual injuries. There may also be anger related to the feelings of loss – of previous physical and mental capabilities, and of social roles and identity before the brain injury. The work of neuro-rehabilitation units is outlined, related to the different stages of recovery. The place and contribution of art therapy is illustrated by a case study of a young man injured on a sports field, and the way he used teenage cultural symbols to describe the way he felt and the difficulties he experienced in controlling his anger.

Chapter 14: Not Being Calm: Art Therapy and Cancer This chapter looks at the role of art therapy in cancer care, as providing a safe place for feelings which cannot be expressed elsewhere, especially anger. Two case studies show how art therapy helped a patient and a family member supporting a patient, to express their anger and find creative means of working with it. A final section discusses some of the literature on art therapy and cancer care, especially the role of anger and the different ways it can be manifested.

INTRODUCTION

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Chapter 15: ‘Came Back – Didn’t Come Home’: Returning from a War Zone This chapter focuses on a case study of an Australian Vietnam war veteran who returned from six months’ active duty and became increasingly unable to function due to post-traumatic stress disorder (PTSD) symptoms gradually taking over his life. This included a gradual build up of anger at the way he had been treated on his return and at the futility of the war. The case study shows how he used a wide variety of art materials, both in his home studio and in the art therapy sessions, to work through different layers of anger, and how he came to a resolution through visual means.

Acknowledgements I would like to thank the following for their interviews: Jo Broadwood, Saf Cooper, Fran De’Ath, Jill Gabriel, Pam Gully, Suzy Jackson, Rosy Martin, Paul Monaghan, Katina Noble, John Ruffle, Martin Schackerley-Bennett, Jan Simpson, Nigel Singer, Jim Sinkinson, David Snell, Hilary Templer, Cathy Waithe, Barry Winbolt and Becky Wright.

References Dryden, W. (1996) Overcoming Anger: When Anger Helps and When it Hurts. London: Sheldon Press. Fisher, M. (2005) Beating Anger: The Eight-point Plan for Coping with Rage. London: Rider. Gerhardt, S. (2004) Why Love Matters: How Affection Shapes a Baby’s Brain. Hove: Routledge. Goldstein, A. and Glick, B. (1987) Aggression Replacement Training. Champaign, IL: Research Press. Hanh, T.N. (2001) Anger: Buddhist Wisdom for Cooling the Flames. London: Rider. Kaplan, F. (ed.) (2007) Art Therapy and Social Action. London: Jessica Kingsley Publishers. Lerner, H. (2004) The Dance of Anger. London: Element Books. Liebmann, M. (ed.) (1994) Art Therapy with Offenders. London: Jessica Kingsley Publishers. Liebmann, M. (ed.) (1996) Arts Approaches to Conflict. London: Jessica Kingsley Publishers. Novaco, R.W. (1975) Anger Control. Lexington, MA: Lexington Books. Novaco, R.W., Ramm, M. and Black, L. (2000) ‘Anger treatment with offenders.’ In C. Hollin (ed.) Handbook of Offender Assessment and Treatment. London: John Wiley & Sons. Tavris, C. (1989) Anger: The Misunderstood Emotion, Revised edition. New York, NY: Simon & Schuster. Whitehouse, E. and Pudney, W. (1996) A Volcano in My Tummy. Gabriola Island, BC: New Society Publishers.

Part I

Children

Chapter 1

The Anger of Abused Children Maggie Ambridge

Introduction The children whose stories are recounted here were referred to the Child and Adolescent Mental Health Service (CAMHS) team where I work as an art therapist, specialising in child protection with a focus on sexual abuse. Referrals are made to the wider team and allocated to appropriate professionals. Art therapy has substantial credentials as an effective way of working with children (and adults) who are often (for complex reasons, including fear, shame and lack of adequate language) unable to verbalise their experience. For a child who has been sexually abused, feelings of anger and rage are inevitably involved. Expressions of anger, however, take varied forms. They may be internalised, turned in on the self, resulting in depression or self-harm, or externalised, turned outwards as aggression towards others. Each child’s individual experience and response may be dependent on factors including age, gender, learning difficulties or attachments, as well as family circumstances. These accounts document the experiences and outcomes for a boy whose progress was followed from age eight to 17, and a girl with learning difficulties and her much younger brother.

Billy’s story Billy was eight years old when I met him. He had recently moved to the area with his mother, stepfather and his slightly older brother, Steve. Billy was referred to the team by his general practitioner (GP) who explained that Billy’s natural father was already in prison, after being found guilty of the sexual abuse of Billy’s brother and also two much older half-brothers from their mother’s previous relationship. What had happened with Billy was less

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clear. All the boys had received counselling, but Billy was at an early stage in the process and his mother was keen to engage further help, as she felt he had not fully coped with past traumas. The case was accepted by the specialist Child Protection service and it was agreed that Billy would attend art therapy sessions to allow him to express and explore his emotions at his own pace and without pressure. The fact that Billy had experienced therapy elsewhere, using art and play, made the transition easier for him. The project worker from this service also provided additional information. Billy had expressed fear of being killed when Dad left prison, being bullied at school and feeling scared at night. Themes in his play had focused on getting rid of poison, drugs and germs, as well as beating up baddies and locking them up, and Billy had been experienced as powerful and controlling during sessions. At our first meeting, Billy’s mother told me that he was angry, ‘hard’ and naughty; he would smash things, rip up pages of his schoolbooks, get into conflict at school and steal. As well as being angry, however, Billy was a friendly boy, who enjoyed sport, and, despite his denial of pain, he had sobbed when his birth father left. The family, including Billy’s ‘new dad’ – a protective stepfather – had just moved and Billy had started attending a new school. Billy quickly became engaged in art therapy and was eager to attend. He told me that his brother Steve did not have the same bad memories as he had. It is possible that Billy’s earliest ‘bad memories’ may go as far back as pre-birth. Billy was born by emergency Caesarean section following an incident when his mother was beaten by his father. When Billy and Steve were younger, their parents separated and their father had ‘looked after them’ while their mum was at work. It was the older boys, Billy’s half-brothers, who, in order to protect their young siblings, eventually disclosed their own abuse. It had taken place in their father’s flat, where he had apparently plied all the children with drink and drugs, which contributed to the confusion surrounding exactly what happened on each occasion. There remained a lack of clarity about the injustices Billy endured, which, in turn, caused him to regress and become aggressive and angry. In his first individual session Billy made a drawing (Figure 1.1) which he described as ‘a man looking into a mirror,’ adding, ‘but it’s the wrong face. When he looks in the mirror he should see a happy face, but he sees a mad face. I don’t know why.’

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Figure 1.1 Billy: A man looking into a mirror.

During another early session Billy painted ‘sea and sand’, an abstract surface of yellow and blue which served as a backdrop to a story he proceeded to play out. The theme involved a rescue helicopter, ambulance and stretcher ‘rescuing a man from the sea’. This seemed to establish Billy himself as having been rescued and now being in a place where he might safely express his unresolved anger (and, perhaps, his underlying remaining fears). Billy continued to produce expansive colour washes as if, in preparing the background, he was delaying the subject of his anger. Another time, after rejecting his first attempt he later returned to paint over the original yellow with a dark murky colour, finally abandoning the painting, unable to say anything about it except ‘I just drawed.’ His inability to attach any description or understanding to the image echoes the uncertainty in other people’s minds surrounding Billy’s abuse. As recollections gradually emerged, Billy said he wanted to do a drawing of a bad memory. He described his father hitting him, and disclosed that he (Dad) had also thrown a knife, but it had missed him. He had felt unable to tell his mum about it. Billy then made an image of ‘sharks with dangerous mouths’. The sharks with their sharp teeth (like the knife) seemed resonant of this frightening experience – and I wondered if perhaps he had been threatened with sexual or physical abuse to prevent him telling. He

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denied being still worried about being hurt by Dad, but seemed unsure about where he was, saying ‘He’s in jail – he’s out now, I think – he won’t know where we are.’ Billy presented with a combination of machismo, vulnerable insecurity and lack of confidence. He continued to intersperse artwork with play using toys. After tying a toy man to a string he said, ‘He’s getting hanged because he’s done something wrong,’ adding, ‘but he hasn’t any more,’ an allusion that could be either to the fact that the wrongdoing had stopped, or that it was uncertain in respect of Billy. Figures alternately attacked each other. There seemed to be confusion about reversals and change, whether moving on wipes out what went before, and, if so, why was he still worried and angry? Billy’s verbal narrative and descriptions during play and image-making in art therapy sessions offered clues to what he may have experienced, subsequently emerging as fear, anxiety and anger. Comments during play with toy figures such as ‘He’s asleep and he doesn’t know he’s being tied up’ seemed to indicate dissociation, a way of absenting himself and not knowing what was happening. Another time he climbed on a rocking horse and told me he was ‘injecting its eyes’, thus making it impossible for the horse to see what was going on. Billy’s confidence in expressing angry feelings overtly towards an identified subject increased when he asked if he could play with clay. He seemed to take comfort in what became a regular routine of opening the clay bin, putting on an apron and pounding the clay. Billy worked the clay into a solid mass, then into a figure with a ‘little head’, then knocked the head from the body, laughing. He put the head back on, and attached a long, pendulous shape, which he said was a nose. I commented that it was a very long nose. Billy said this was because he’d been telling lies, like Pinocchio, and then punched the figure, knocking its head off again, and saying ‘He can have a ton weight on him now.’ He rebuilt the figure and again punched it several times, saying, ‘That’s for my mum, that’s for my dad and that’s for Steve.’ I commented that he was angry on behalf of other people and wondered if he was a bit angry with the man for himself as well. Billy replied by stabbing the clay figure with a big paintbrush, ‘a sword’. Was this what Billy wanted to do, as punishment? ‘No,’ he said, ‘it’s not enough, nothing would be enough.’ He went on hitting the clay energetically, singing ‘He’s dead; he’s got a big hole in him.’ I wondered if, as he was dead, Billy could stop worrying about him, but this would take time.

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Billy’s angry revenge continued. On one occasion he painted his hands and asked for paper, smacking his hands down to make handprints. The action escalated, with more paint and more slapping on to the paper, until Billy made a fist and began thumping, punching the paper ‘Watch this,’ he ordered. ‘Are you watching? I’m squeezing the blood out of my dad now.’ As Billy discharged his anger he hurled paint onto the paper, splashing both me and the wall, then, having reached a crescendo, decided to wash the paint off his hands and play with the clay. He made another clay image of ‘old dad’, saying, ‘I’ll rip his legs off and punch his arms off and keep his head.’ The dismembered figure, thus made physically helpless whilst retaining the knowledge of what he had done, was kept alive to be punished for further remembered cruelties. One day Billy said he had become a good lad, with more friends. He was doing well at school and felt that he was not so cross any more. He seemed to have achieved some separation between the passionate anger he expressed through art therapy sessions, and the amiable good lad he wanted to be. In the same session he cut his clay man in half, down the middle. Dissociation by ‘splitting’ may have served as a coping mechanism for Billy, during abuse and afterwards, by enabling him to cut off from unbearable memories and knowledge. Themes of knowing, not knowing, not hearing or seeing, and guessing games such as ‘Hangman’, ‘I Spy’ and ‘Hide and Seek’ often emerged in his sessions, replaying the uncertainty of family and professionals about his abuse – had he been physically or sexually abused, or had he been ‘only’ in the grooming stage? Remaining in this uncertain limbo has not been an easy place for Billy. The details of what actually happened (and what may have been masked by drugs, lies or threats) are often difficult for young children to recall in words. The indignities and fear he suffered and recalled as well as others he had been told of, more than account for the sum of his anger. Following a routine but invasive and upsetting operation, Billy replayed his own traumatic birth scene with toys. A mother bear had to have an operation because ‘she’s got to have the baby out. She’s got something wrong with her heart.’ Once the baby bear was safely born it was the big (father) bear’s turn to be operated on. ‘He’s been punched. Cut him open, snip, snip. He’s got cancer.’ Billy’s anger was exacerbated by his love as well as his hate for his abuser. It was unclear whether he was punishing or healing him.

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Billy continued to attend for about a year. During this time, perhaps hastened by his father’s imminent release, Billy remembered some ‘scary incidents’ and decided to make a statement to the police, finding some relief in this. A planned ending to the therapy was put in place with an acknowledgement that Billy might need to access further help later. When he was aged 11, Billy was re-referred because, now at senior school, he was again having difficulty controlling his temper, and had asked for help. He described his fear that he might hurt someone, and was keen to learn to control his temper, remorsefully recalling fights and arguments he had previously been involved in, and saying, ‘I’m not an angry sort of person. A lot of people tell me I used to be.’ Billy’s two sides, gentle and violent, were now being acknowledged and brought into the arena for discussion. He was able to openly confront the fact that he was still drawn towards situations where he might become involved in fighting, and, being a well-built lad, he was likely to inflict pain. He said, ‘I don’t want it to happen but it does.’ Fighting reminded him of his anger towards his real dad and prompted him to create an image of a brown bear (recalling the ‘operation’ on the bear when he was younger). He cut out the head and stuck it on another sheet of paper. ‘Just his head. His body got chopped off ’ – again, an image echoing his own dissociation. Billy continued to work at making sense of his angry feelings which conflicted so much with his otherwise gentle disposition. He attended for the school summer term, and after the summer break did not need any further sessions. Five more years passed, and Billy, now a well-functioning, amiable young man, doing well educationally, requested some more help. He admitted that he was still occasionally drawn into conflict situations, and was happy to discuss this. However, the other reason for his attendance was to revisit the intervention he had as a much younger boy, by going through the records of his earlier sessions over a series of appointments. He remembered much of the process and was able to consider it from a more mature vantage point. The issue for him now, was about finding a way to achieve some resolution with his ‘Old Dad’, now out of prison. When we last met, Billy was still considering a visit to put things to rest, and thinking carefully about his options, acknowledging the reality that he and his brothers were now likely to be stronger, physically and emotionally, than their aging father; strong enough not to resort to the bullying, abusive manner in which he related to them.

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Eliza and Jamie’s story This begins with the distressing changes witnessed in a 12-year-old girl, Eliza. Whilst coping with considerable learning difficulties, she had a sunny, loving personality and was the pride and joy of her patient, caring mother, Karen. Eliza had been happy and confident at her special school, but changed unexpectedly into a diffident, moody child. She regressed and started soiling, crying frequently and losing previously acquired skills. The joy she had shown towards her baby half-brother turned to a resentful anger. Baby Jamie was later to display his own fury. When abuse is hidden, as it usually is, there is often a great deal of irrational anger turned towards the mother. For many children who may have been threatened it is too dangerous to show anger towards the abuser directly. For others, like these siblings, there may be additional difficulties which prevent telling. A lack of understanding (because of learning difficulties) or language (owing to pre-verbal age) renders them easy targets who may be perceived as being unable to put their experiences into words.

Eliza’s story The emergence of Eliza’s story was preceded by physical symptoms, which might have been identified earlier as indicators of abuse had they not been masked by her disability and the acceptance of a developmental explanation. Eliza was initially referred to the CAMHS team by her paediatrician because of major behaviour problems, including wetting, soiling and smearing of faeces: symptoms that would usually ring alarm bells. However, after a short family therapy intervention and increased medication there was a perceived improvement, and the problems seemed to be accounted for by a number of changes in the family which could have unsettled Eliza. These included the separation of her birth parents and a subsequent new relationship resulting in the birth of a new baby brother. The soiling had apparently started when he was born, and coincided with a recent change of class at school for Eliza; enough, it seemed, to explain the disturbed behaviour. Her mother, however, retained an instinctive feeling that something had been upsetting Eliza inside that she could not explain. Some two years later and only after her stepfather had left the family home, Eliza began to make disclosures of sexual abuse. The manner of her disclosure, little by little, and to various trusted people in stages after ‘testing the water’, is indicative of her gradually finding a narrative for an experience

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of which she had no understanding. It became clear that many of the problems were likely to have been caused by undisclosed abuse. Eliza was re-referred to the CAMHS team for therapy by her paediatrician. This time she and her mother were taken into our child protection service. Now aged 13, Eliza experienced disturbing and explicit flashbacks of the abuse. She had no comprehension of how someone could deliberately hurt her, and expressed puzzlement that ‘he didn’t say sorry’. Eliza cried and accepted comfort from her mum, after describing cruel physical and sexual abuse. It was more difficult for her to express the anger that was underlying her tears. She loved to draw, but her images were of ‘happy things’, such as flowers and sunshine, perhaps reflecting her mother’s urgent wish to make things better for her, and Eliza’s wish to please. At home drawing a picture was used as a technique to distract Eliza from distressing thoughts and replace them with happy ones to help her recover from distress as quickly as possible. This was important in restoring routine, especially as Eliza’s learning disability caused her to hang on to thoughts in a repetitive way. However, it prevented her acknowledging the underlying rage that needed to be released, and she became quiet and withdrawn rather than angry. Towards the end of a year working with the family, and almost three years after the concerns first came to light, both children were able to unlock more of their anger productively in therapy sessions. After a break, her mother requested a further appointment for Eliza to help her to move on from her disturbing ruminations. When I saw her again there seemed to be a qualitative difference in her artwork. Previously she had routinely, and almost mechanically, produced the repetitive ‘safe’ images about feeling better and everything being OK – usually embellished with pretty flowers for Mum. This time I suggested she might draw the person who had hurt her. Eliza immediately said she would draw ‘the naughty monkey’ (Figure 1.2). As she drew, her anger was released: Eliza talked directly to the emerging image, ‘No, I don’t like you. He can be the bad man, the naughty monkey. Naughty, don’t like you, you monkey head. You’re bad, you’re fired…get out, go away. You can go away very far because he’s naughty doing that to me.’ ‘I want to make him messy; he’s going to be miserable, sad, lonely and dead. Stop making me miserable and go away and out of my house and lock the door.’ ‘Stop looking at me. I’m better than you – you pineapple!’ she shouted, gleefully squashing the drawing paper, ‘Keep out of my house, it’s mine and Mummy’s and Jamie’s and the cat’s. I hate you. Go away and leave me alone

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Figure 1.2 Eliza: The naughty monkey.

now.’ Eliza scribbled all over the image of the man, relishing her revenge. She was happy for me to symbolically lock up her picture (and thus the abuser) in my office, and proceeded to make a pretty card for her mother representing ‘happy feelings’, emphasising this was ‘not for you, you bad monkey head. I’m thinking about Mum now. She’ll be the happiest person in the house.’ Working in tandem with the non-abusive parent alongside the child can have a significantly positive effect on the outcome (Ambridge 2001). Eliza’s ability to express her anger in such a direct way was almost certainly made possible by her mother, Karen, acquiring the ability to receive it. The first step was separating from her abusive partner. This enabled her, even before Eliza disclosed the abuse, to think about the way she (as well as the children) had been systematically controlled. Memories flooded to the surface and were quickly shared and addressed in a process which helped her to regain her autonomy and power as a positive, protective and confident mother.

Jamie’s story Over a prolonged period of legal proceedings concerning contested contact for Jamie’s father, Karen worked continuously to restore a reassuring and

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normal life for her children, while also receiving support for herself. Karen attended regular sessions with me, sometimes bringing Jamie with her. Gradually, the emphasis changed more to working with Jamie using play and art therapy. The first of these sessions took place after a family holiday that was cut short because Jamie had become increasingly upset, scared by loud noises which often seemed to be experienced as aggression. At two and a half years old, little Jamie had himself became loud and aggressive. There had been a constant battle of wills: he was alternately loving and angry towards his sister, and often wanted to hit and fight. His mother reflected sadly, ‘He must have seen a lot of physical roughness.’ Sometimes during the session Jamie seemed particularly angry, hitting his mother and shouting. There was no affect connected to the hitting – it seemed to be mechanically repetitive. He would then apologise, but seemed confused. Over the course of a further year, Jamie found not only the language to make his own disclosure, but both symbolic and concrete ways to extricate himself from any link with the man who had hurt him as well as his sister. Anger may be expressed by very young children, including those at a pre-verbal stage, who may have experienced or witnessed abuse before they have developed the language to speak of it. Their anger emerges initially through behaviour (as for most infants). The traumatised child’s first words, far from being an event for celebration, can contain echoes of the abusive, threatening language of a perpetrator. Expressions of rage, in words or actions, are often directed towards the child’s primary attachment figure, most usually the mother. For the protective parent, this is clearly extremely distressing and frequently experienced as embarrassing and shameful. Similar emotions and behaviours may be replicated during therapy sessions. So it was with Jamie. He had always been demanding and particularly clingy to his mother. He had also been slow to talk as the result of an early ear infection. However, when he did begin to talk, his vocabulary developed rapidly and came out in full sentences, especially when frustrated by his sister’s distraction and distress. Some of his words were controlling – ‘I’m very cross with you…Eliza’s naughty.’ At other times Jamie was gentle and comforting to his big sister, saying, ‘It’s alright Eliza. That’s a bad man to do that to you.’ Some things Jamie said seemed to describe disturbing events he might have witnessed, or echo words he had heard. Even more alarming were incidents at nursery of bullying and sexualised behaviour. Jamie was seen to

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pull down the clothes on an anatomical boy doll, lick its penis and put it into his mouth. He was also witnessed grabbing other children from behind and making thrusting movements. This acting out is not uncommon in children whose abuse has been during a time of little language ability, so that, by age three, ‘it is not unusual to see children this age play out sexual abuse scenarios with each other’ (Hewitt 1999, p.35). At home Jamie had been observed, whilst playing with a dolls’ house, frequently to hit and throw the ‘Daddy doll’ before hiding it, telling the other dolls: ‘It’s alright now. He’s gone.’ He was also scared of certain foods. During an appointment with his mother, Jamie played out more of the story that had begun to emerge. Despite now having a wide and sophisticated vocabulary for his age, his speech was still unclear. He constantly referred to his mother and was reluctant to converse directly with others. Jamie presented as very labile, but Karen could usually calm him. He kept close to her, whining and crying whenever something minor went wrong. Predictably, Jamie was drawn to the dolls’ house in the CAMHS play therapy room. He looked for a ‘Daddy doll’ and having found one said, ‘Put him in the bin – he’s a daddy.’ Jamie then began to talk about monsters. His mother confirmed that this had become quite a preoccupation at home, and that for Jamie the front door was a monster. Later that day, at home, Jamie disclosed that he had been physically abused in the vicinity of the front door, saying, ‘the monster-man (naming his father) hit me near the front door.’ Over subsequent days and weeks more explicit disclosures of sexual abuse including oral penetration emerged in quick succession, and a multi-agency strategy meeting was called. This turned out to be the source of some frustration; Karen was upset by what she described as the scepticism of the majority of the professionals present, who found it hard to believe that a child could recall events from such a young age. Jamie’s part of the story is remarkable in the way it challenges us as professionals to understand the development of thought and expression of very young children in relation to their experience. This process, between the ages of eighteen months and three years, is described in some detail by Hewitt (1999), who refers to autobiographical memory typically beginning around the age of three. Jamie’s disclosure came in a series of events, from unformed rage, through acting out, to telling. The fact that he was enabled to do this emphasises the importance of the role of a mother who was able to help frame her child’s recall into a narrative form while patiently waiting for the story to emerge, without imposing her own interpretation. For the very

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young child, the image is present before words or the ability to make the image concrete. Infantile anger, therefore, becomes the primary medium for communication. The next time I saw Jamie, he drew two pictures very quickly before wanting to play (Figure 1.3 and Figure 1.4). It was the first time I had witnessed him deliberately making images. Reflecting on them later, I realised that they perhaps echoed the two images Eliza had made in quick succession. The first of Jamie’s drawings appeared disconnected and random; a toddler’s disintegrated scribble. The drawing made immediately after, however, was clearly representative of a figure, appropriate to his age ability, and showing a child’s understanding of himself as a separate individual.

Figure 1.3 Jamie’s first drawing.

Identity was an important issue for little Jamie as the only family member to bear his father’s surname. As he became aware of this, at play school, medical appointments and so on, much of his anger was focused on refusing to accept it, and becoming upset and aggressive when referred to by his father’s surname. Happily, the eventual legal outcome enabled Jamie to change his name and all claims to contact were withdrawn by his father. The fact that

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Figure 1.4 Jamie’s second drawing.

Jamie’s externalised anger was responded to and acted upon was instrumental in securing his own feeling of safety within his family.

The role of art therapy Art therapy is a particularly appropriate intervention for abused children as it enables expression of the unspeakable through image, metaphor and symbolic play, at a pace controlled by the child. The setting provides consistent protective boundaries of physical space, safety, time and place. The therapist’s role is not to impose but to trust in children’s sense of what they need to do; to enter the child’s world alongside him or her as a witness to the emerging story of their experience. For Billy, the methods used in art therapy were largely non-directive, with no expectation or direction about content or choice of media from the

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art materials and toys available. He used a rich combination of imagery, made up of drawing, painting, clay work, symbolic play with toys, and word games; themes involved looking for clues, answers and problem-solving along with danger, anger and revenge. The intervention was reflective, using verbal feedback to respond to what Billy was doing, making or saying, and allowed him in turn to reflect on and achieve mastery of the narrative, contributing to his eventual ability to find some resolution, for example in talking to the police. Billy also developed trust in the therapeutic process, which enabled him to feel comfortable in accessing further help at different life stages. Owing to her learning disability a different approach was indicated for Eliza, to accommodate her concrete and repetitive thinking as well as her traumatic abuse. Her needs for reassurance and nurturing were those of a much younger child, and it was appropriate for her mother to be closely involved in the therapy. In early sessions the repeated flowery images and messages of love for her mother represented Eliza’s need to retain reassurance of her mother’s reciprocated love and protection in order to feel safe; this elicited an immediate, positive response. Later on it was possible to be more directive and Eliza responded immediately to the suggestion that she might want to draw the person who had hurt her. She subsequently moved from a victim position to one of strength in which she was able to externalise and express real anger by symbolically attacking and abolishing her abuser. Jamie’s very young age and anxiety made it appropriate for him to be seen with his mother for a limited number of sessions. Using free play with toys and art materials enabled him to create family scenarios that indicated family attachments, fears and anger. Both children thus discharged anger appropriately and eventually the angry behaviour at home diminished.

Epilogue Sadly, there are countless more stories to be told of the anger of abused children. These are just two of the many I could have chosen from my practice. Each one is unique yet also holds threads common to every other experience. Anger is not always towards the abuser. It is often directed towards a carer or attachment figure, whether protective or non-protective. Anger is routinely turned inwards, more often (but not exclusively) by girls, as self-harm; or acted out through risk-taking behaviour, aggression, violence, sexualised behaviour or replicating the abuse that has been experienced. Sometimes, we, as therapists, are recipients of anger which must then

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be held and worked with. In my experience, there is always a splitting, dissociative process – the angry child, adolescent or adult countering the frightened, vulnerable infant. The hurt child is at the heart of our work.

References Ambridge, M. (2001) ‘Using the reflective image within the mother–child relationship.’ In J. Murphy (ed.) Art Therapy with Young Survivors of Sexual Abuse. London: Brunner–Routledge. Hewitt, S. K. (1999) Assessing Allegations of Sexual Abuse in Preschool Children – Understanding Small Voices. London: Sage.

Chapter 2

Anger Management with Children and Young People: Creative Tools to Mend Broken Tempers Leila Moules

Introduction The Child and Adolescent Mental Health Service (CAMHS) where I work in the north of England frequently receives referrals for children who are experiencing angry outbursts, damaging their relationships at home and at school. Often, the adults involved are bewildered by such extreme behaviour, in which harm is inflicted upon the child, others and inanimate objects. Unfortunately, the result can be the threat of permanent exclusion from school and, ultimately, being taken into care if the situation deteriorates too badly. Parents fear that their children getting out of control will have disastrous repercussions, resulting in their imprisonment when they achieve the size and strength to hurt someone seriously. By the time they resort to seeking a referral to the CAMHS, parents have generally exhausted all their capabilities. They feel ‘at the end of their tether’ and mostly blame themselves for failing. It may transpire that their child is having a normal reaction to abnormal circumstances, but parents are too immersed in the situation to notice. As CAMHS workers we hope to reduce this guilt, as it can be paralysing, preventing parents from being effective in their roles. However, sometimes parents have unrealistic expectations of what we can achieve with their child. They acknowledge the fantasy that we can ‘wave a magic wand’, ‘give the child a magic pill’ or restore the child to how they were ‘before’ – the trauma, the divorce, the sexual abuse. Underlying this wish is the knowledge that challenging and promoting change in such behaviour is a difficult and wearing task. 42

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As an art psychotherapist I use creative processes to help children gain insight into their behaviour. In the first instance I have to be clear that they want to change. Getting angry is a defence mechanism and part of the ‘flight or fight’ response, which we all have to learn to manage. Consequently, at CAMHS we undertake a thorough assessment, usually with two members of the multidisciplinary team. The outcome is a naming of the problem, such as temper outbursts or more diagnostically, ‘Oppositional Defiance Disorder’ (WHO 1990, p.270). We also come up with a working formulation and a treatment plan the family agrees with. Children who are struggling to contain their rage often do not recognise the seeds of anger, until they erupt all over the house or classroom. Then they become too full of shame and hurt to reflect on where it started. I use art, play and relaxation to help a child to feel secure enough to be able to ‘look within’. Through the development of insight it is hoped that children will gain some control of their impulsive behaviour and do their bit to easing the tensions of the family. Parents, too, are encouraged to make changes, with support from a co-worker, who could be a psychiatrist, social worker or clinical nurse specialist, thereby enabling the household to do things differently. Early on, I like to ask the child or young person, ‘Do you think I will be able to help you?’ This is an important question as the answer indicates whether the child is open to making changes and optimistic about things being different, independently of the parents. I invite them to give me a response on a zero to ten scale (zero being the least and ten being the most). This gives us the opportunity to think about the future and a potentially successful outcome, and I elicit some clues about whether we can work together to achieve this. It also helps to know if the child accepts some responsibility for their temper, rather than blaming it on other people ‘winding them up’. Children and adolescents can sometimes display omnipotence, making them difficult to reach. This may sometimes indicate symptoms of a pervasive developmental disorder, and this possibility needs to be considered as part of the assessment process. I talk about anger management at different levels, according to the age of the child and their ability to understand. I describe the process as ‘giving them a toolkit’, to mend the anger. Sometimes I frame anger management in a different guise: that of anxiety management or relaxation therapy. Depending on the presentation of the child, I start the work from a different point; the tools are the same, although the branch leading to the ‘toolbox’ is

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different. Extending the tree analogy further, fearfulness and anger arise from the same root. ‘Marked aggressiveness and tendencies to show superiority over others, for example, often originate from fear and uneasiness’ (Sandström 1983, p.182). So some of our work is helping parents to perceive that their child’s behaviour is not driven by naughtiness but fear. Applying appropriate parental management to such a situation may be the opposite of enforcing punitive measures.

Working with children and families I try to make the experience in the play room, where the art therapy sessions take place, an interesting one. This can engender an openness to learning and new ways of being. It is important groundwork for establishing a safe relationship with an adult (someone other than a relative or teacher), in which the child can practise new behaviour. As an art psychotherapist I am alert to what the child might be telling me about their internal world, through the symbols and themes emerging in the art work or activity. I also pay attention to my countertransference responses. For whatever reason, negative relationships are sometimes established in families. The parent’s attitude to the child is of great importance. Unfavourable comparisons with other children, lack of acceptance, making the child feel an outsider, threats of physical punishment: all cause emotional strain and harm (Sandström 1983, p.177). This is obviously an extreme description, and we rarely encounter such circumstances in our clinic. The majority of families we see are struggling to manage an aspect of their child’s behaviour and the relationship is still intact enough for them to care. Often, angry outbursts are denied by the child, who claims no recall whatsoever, whereas other members of the family are left quaking after the experience of a ‘domestic tsunami’ wreaking havoc in their home. Parents often describe the states their children get into as ‘Jekyll and Hyde’ in character, or say that their children’s eyes ‘go blank’; sometimes they say that the child behaves as if possessed by an evil spirit. Certainly there is an unrecognisable quality in the child they know and love. Epileptic investigations are requested for some children, to rule out absences of an organic origin. Rarely do they return with anything definite but such is the magnitude of their child’s presentation that parents feel ‘there is something wrong’ and fear it could be located in their child’s brain. It is difficult to be mandated to effect a cure for something the child does not remember. If the child has no memory to work with, we may not offer therapeutic work. As clinicians we understand that the temper has a function

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and is a form of expression within that family. We interpret the behaviour as a symbol of frustration and distress, but triggers may be more difficult to locate. In these circumstances we concentrate on offering parents support, by meeting to discuss management styles. Sometimes it emerges that parents are experiencing difficulties within their marriage, but do not think the children are aware of this. Or maybe the family is enduring financial hardship, or a parent may have mental health problems. Finding out about these situations of adversity helps to make some sense of the child being the ‘node of expression’ for that particular family’s distress.

The reluctant participant As a way of offering some help for family tensions, whilst not focusing on ‘the angry behaviour’, we may offer the reluctant participant the opportunity to come into the play room and ‘have some time for themselves’. This is framed as part of a continuing assessment process and the child comes into the play room for a number of sessions, usually three. The aim is to obtain a view about the child’s internal world and why they might be expressing themselves in such a destructive way. It is hoped that the invitation provides the child with a safe neutral space, which is ‘their time’. Such sessions are often a prelude for further anger management work, which the child does agree to after establishing a relationship, secure in the knowledge that their mode of expression is not going to be taken away. A neuropsychiatrist working with our team was encouraging about the value of such work because, given the plasticity of a child’s brain, it would open neural pathways hitherto not stimulated into action. In the therapeutic space, new connections are promoted, enabling behaviour to change. This links with some ideas of Wilfred Bion, a group analyst and psychotherapist whose work has influenced me. Bion developed an interesting use of notation to describe the primary relationship between mother and infant, culminating in learning, which he called ‘K’ activity. K stands for knowledge but is different from acquiring ‘pieces of information’. K is ‘coming to know’, a bringing together of emotion and cognition (Malcolm 1992, p.122). In my benign role, I am not insisting that the child cleans up the bedroom, does homework or comes off the computer to let their little brother have a turn. I do not become the object of hatred, triggering the rage and sense of injustice in the world that so many of the children present with; interestingly, mostly boys. I can ask reflective questions such as, ‘Why is it such a problem, when you are asked such and such? Can you try to help me to understand?’

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The anger management toolbox Over the years I have been working in CAMHS I have adopted a series of techniques to help teach the management of anger. I use the concept of the ‘toolbox’ with children and families to imply that something practical can be used to help ‘mend’ the problem. These are contained in a colourful A4-sized anger management folder that I give to the child and which includes the following: ·

anger diary

·

anger rating scale

·

relaxation techniques

·

angry words.

In addition I use the following art therapy methods: ·

sketch book

·

blue and black breathing image

·

body drawing outline.

The order in which I use the items in the ‘toolbox’ varies. Exercises are introduced when I feel the child is receptive to the information. I ascertain this through the developing relationship with the child and how they interact. Are they relaxed and comfortable? Do they smile readily, laugh at my jokes, tell me jokes and make eye contact? Do they listen to guidance about using art materials, especially care of the brushes?

The sketch book I have chosen to describe the sketch book first because it is often the first tool I introduce. When the children do want to do something about their temper, I try to encourage them in accessing and recalling their ‘Mr Hyde’ by ‘helping me with some detective work’. At the first session or even at the end of the assessment consultation, I ask them to choose a sketch book from a selection I have in my store and ask them to ‘try to draw their worries or troubles’. I explain they might forget about these thoughts or angry feelings by the next time they come to see me. It might be easier to draw incidents or write about them; anything they think might help me to help them with their problem. I encourage the ‘detective alter ego’ and remind them they are not just watching themselves but also what happens in their family. Maybe they are ‘not all to blame’. In this way I enter into an allegiance with the child

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or young person, being prepared to accept their version of ‘the truth’. This does not mean I collude with the child. My role is to help process some of the raw feelings and try to help everyone with the ‘coming to know’. The sketch book fulfils three purposes: encouraging visual thinking, development of insight and maintaining the connection between the therapeutic space and home, serving as a tangible bridge between the two. I involve parents in the process by asking them to remind the child to bring the book to the next session and to prompt any use after an outburst, obviously when things have calmed down! I reiterate that the contents of the sketch book are private, to be shared only if the child gives permission. Symbolically, the sketch book is a vehicle of change, the re-appearance of which gives some indication of the strength of the allegiance between parents, child and therapist. My perception is the more the sketch book returns to the session the greater the likelihood of a positive outcome. An example of the use of the sketch book was shown by a teenage boy diagnosed with Asperger’s syndrome. He had drawn a series of pictures in his book about the worrying things in his life. One picture showed him at the local swimming baths, in the deep end without arm bands, in a state of considerable anxiety. As he explained his feelings I related to the sentiment by saying, ‘You know, sometimes life feels like that.’ He surprised me by spontaneously laughing at my off-the-cuff remark, especially as one of the features of Asperger’s syndrome is a lack in understanding of humour. I thought he could be showing me what it might be like for him to be in this therapeutic space, although I did not share my interpretation at the time. It seemed we had made enough of a connection in that moment with shared laughter.

The anger management folder As referred to earlier the folder contains four sections, as follows.

Anger diary I ask the child or young person to use the anger diary (Figure 2.1) to record angry episodes until I next see them, either by writing or drawing. Often we leave the anger rating scale column until the following session when we have time to talk about the process of rating anger on a zero to ten scale, which is a separate exercise. I try to be mindful of not burdening the children with what might seem like more homework in an already decreasing amount of leisure time. At the end of the session I fill in the dates of usually two sheets, until

Figure 2.1 Anger diary.

Sunday

Saturday

Friday

Thursday

Wednesday

Tuesday

Monday

Day

Time

Situation and what happened

Who was involved

Feelings

Anger rating scale

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our next meeting, and say we will discuss any incidents that might occur. Sessions at CAMHS are usually fortnightly.

Anger rating scale The most important feature of the anger rating scale is a diagram of a staircase ascending to the top right-hand corner, numbered from zero to ten. Standing on steps 3 and 4 are people symbols, indicating where the child might be when they are having a temper outburst. At the bottom of the page is a double-headed arrow, labelled ‘Impossible to Think Clearly’. For most of the children who undertake this work, by their own account, not only is it impossible to think clearly, it is hardly possible to remember being on the staircase! Anger rating

Angry words

Physical sensations

Midly irritable Irritable Mad Angry Very angry 10 9 8 7 6 € €

5

4

3 2 1 0 Impossible to Think Clearly

Figure 2.2 Anger rating scale.

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The staircase provides a framework for thinking and experiencing anger objectively. I see my task with clients as acknowledging how difficult thinking is, when ascending the anger staircase. The plan is to help them in the play room, when everything is calm, to give the anger aetiology some thought, thereby removing the high emotion, guilt and shame which interfere with cognitive processes. As adults we forget how difficult it was to control our childhood rage, although some adults never do learn to do this. Anger and hatred are two of our closest friends. When I was young I had quite a close relationship with anger. Then eventually I found a lot of disagreement with anger. By using common sense, with the help of compassion and wisdom, I now have a more powerful argument with which to defeat anger. (Reprinted by permission of HarperCollins Publishers Ltd. © HH the Dalai Lama 1999, p.51)

When I am working individually with children, I try to normalise anger as a helpful emotion, describing how it tells us something about our situation, being part of the ‘fight or flight’ response. For example, in past times when humans lived in caves, we would need to escape from tigers, who might think we looked like a tasty snack, or fight them off with a sharp stick! I explain how everyone gets angry as part of this survival mechanism but how their reaction may have become distorted (unless they have a man-eating tiger for a pet). Even the Dalai Lama admits to struggling with his emotions when young. Parents experience problems when temper tantrums become habitual and escalate into destructive rampages, eroding the fabric of the home and family life. At the CAMHS, we tend to take a family systemic approach and perceive the whole family as experiencing ‘the problem’ rather than focus solely upon the child. As discussed previously, parents are invited into the clinic by a co-worker, who helps explore their child-management styles. Sometimes parents have wildly differing approaches to discipline, leading to confusion for the children. This creates opportunities for dividing adults, and the child (or children) steps into the gap and claims the authority in the relationship. In the short term the child achieves a feeling of omnipotence, but in the long term the child feels insecure and anxious because their parents are not ‘in charge’. Returning to the anger rating scale, I ask the child to describe escalating feelings, correlating to the ascending numbers on the staircase. Starting at ‘mildly irritable’ (my adjective) I try to encourage the child to use their words and create their own vocabulary. Naming these feelings is an important

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process. I encourage a child to identify sensations within the body, in conjunction with the body outline drawing exercise (see below) and write them on the chart. Previously, the child may have been splitting off from experiencing physical sensations, especially those related to anger, because they are so unpleasant.

Relaxation techniques These are taught in conjunction with the ‘Blue and black breathing image’ (see below). The basic relaxation technique is included in the anger management folder as a reminder. There are occasions when I make a tape of the relaxation instructions from the session for the child to take home. Breathing as a foundation for therapy is a popular technique, providing ‘containment’ for anxiety. The focus of using breath (or, in Sanskrit, prana) for healing, originates in meditative practices from the East which have been documented for centuries. My adaptation of the technique comes from Buddhist practice. BASIC RELAXATION TECHNIQUE (IMPROVES WITH PRACTICE)

1.

Sit or lie comfortably, legs and arms uncrossed, with your back straight. Close your eyes if it feels comfortable.

2.

Breathe in and out slowly and deeply. Try to only think about the gentle rise and fall of your chest.

3.

Do not let other thoughts intrude and give yourself permission to take a little holiday from things worrying or troubling you.

4.

Allow any noises outside the room to flow through you and try to concentrate on listening to the sound of my voice and the instructions. Be aware of the peacefulness and quietness we have here.

5.

Imagine your arms and legs become heavy and sink into the chair/floor. (Sometimes, especially when new to this technique, I ask participants to make a firm fist and tense up the muscles in their arms and shoulders very tightly. I ask them to do this three times, releasing the tension each time.)

6.

Imagine you are as still as a statue and your hands and feet become large and heavy like a stone sculpture.

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7.

Focus upon the air coming in through your nose and out through your mouth. Notice the difference between the air coming in and the air going out.

8.

As the cool air comes in, imagine you are breathing in blue light, like the sky on a clear day. As you breathe out, imagine the warm air containing all the used up gasses, is made up of black smoke.

9.

Try and do three complete breaths (in and out is one complete breath) without letting other thoughts intrude.

10. Let the blue light bring with it really good feelings of calmness and the black smoke take away painful feelings of worry and upset, and blow it far away on to the horizon, where it dissolves. 11. As the black smoke takes away these difficult feelings it leaves space for blue light (positive thoughts) to get in. So as we go, you can feel the whole of your body being filled up with blue light. 12. Try to remember the feeling and picture of peacefulness for a few moments before I ask you to wiggle your fingers and toes and open your eyes. (Reproduced by permission of Wisdom Publications www.wisdompubs.org. © K. McDonald 1985, p.44)

One ten-year-old boy, Paul, ‘came round’ from his first experience of relaxation with a contented smile, saying he felt happy. He did not think he had experienced happiness before! Paul seemed flabbergasted by the experience, saying he had ‘always been angry’. Following a ‘therapeutic hunch’, I invited his mother back into the session and we talked about his birth experience, which had been difficult for both of them because it was a Caesarean section. I explained how being born can upset some babies, as it can be such a shock. Paul made a connection with his birth and tempers, and consequently gained some insight into his behaviour. Whether this was accurate or not was difficult to substantiate, but it had meaning for Paul. At the following session, his mother reported considerable improvement and family life attained some equilibrium. There were still occasional outbursts but nothing of the magnitude previously demonstrated.

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Depending on the child’s level of comprehension and attention, I adapt the above version of the breathing technique and ask them to practise once or twice a day, when they wake up and when they go to bed. I also suggest they use the method if they find themselves getting worried or become aware that they are getting cross. In this way, I teach that ‘special breathing’ is like applying an antidote to poison. Angry feelings, I say, are less likely to take effect because the ‘blue and black’ breathing helps to keep them calm. When I ask at the end of their treatment, children generally report this exercise as being the most helpful.

Angry words In the search for a vocabulary to describe anger, I ask the child to continue the investigation and ask friends and family for more words to describe anger. I give them a sheet of paper with a few examples printed on it already, such as ‘Seeing red’, ‘Ballistic’, ‘Mad’, ‘Furious’ and ‘Rage’. Some families have unique expressions to describe tempers: one father described his son as ‘having a tanti’ (tantrum). This sort of information is priceless and gives one a rare glimpse into how anger functions in a particular family. For this boy there was a positive outcome and his ‘tantis’ reduced. All these information sheets interconnect with each other and the image work. Angry Words is particularly useful for the feelings section of the anger rating scale, and the body outline drawing is useful for transferring feelings into sensations, for example ‘shaky legs’.

Blue and black breathing image The blue and black breathing image is generated through guided fantasy, to encourage the use of imagination and stimulate the visual cortex. I have found this method particularly useful for people who are reluctant to make images. I have adapted the visual component of the exercise to ask the child or young person to think about blue light rather than the more usual white light. Blue light seems easier to imagine as references can be made to the sky, which can be seen from the fourth floor of our clinic. To build on this technique and encapsulate the memory of creative visualisation, I ask the child to make a painting of their experience, concentrating on the blue light and black smoke coming into and out of their body. I sometimes draw and paint my experience of relaxation alongside the child, which gives me the opportunity to model the process. The child can observe

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my somatic responses to the breathing technique and how I might transfer that experience into imagery. One eight-year-old boy, Liam, came to the clinic with a list of worrying behaviours: poor appetite, poor sleep and serious temper rampages. Liam’s mother was expecting a baby but he could be aggressive to ‘the lump’, which understandably gave his parents concern. In the play room Liam found it difficult to settle into relaxation and was resistant to my requests to use his imagination and think about a blue sky. He complained he could not see any blue sky out of the window but a previously grey sky suddenly manifested a patch of blue. We both expressed surprise about how this had happened and wondered if there had been some magic! Eventually Liam settled and I asked him to make a picture about his naughty and good sides, which he had identified earlier. Liam responded eagerly and did not need me to draw alongside him. He had an active imagination and would draw avidly whenever he arrived in reception. From the illustration (Figure 2.3.) you can see the ‘naughty side’ (on the left) has horns, an angry scowl, clenched teeth and fists. The blue sky breath or positive feeling is hovering above the body, separate like a block of ice. The ‘good’ aspect (centre) wears a halo. Liam talked about the eyes in the second figure being ‘woosy’ and I recalled an earlier comment he made

Figure 2.3 Liam: Naughty and good sides.

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about being fearful that I was going to hypnotise him. I reassured him there was no point in this, because he had to take charge of his tempers. Finally, the figure on the right of the picture was a mixture of the two, he said. I commended Liam on the way he had put these separate selves together and wondered to myself whether some steps had been made towards integration.

Body outline drawing Following the above activity, in which the child is representing themselves in an image from their imagination, I take the process a step further and at the next session introduce the ‘body outline drawing’. Here the body is on the image (Figure 2.4), making bodily sensations much more tangible. I have a large roll of wide paper especially for the purpose but good-quality lining paper will do. I ask the child to lie on the paper and draw around them with a crayon (Liebmann 2004, p.224).

Figure 2.4 Simon: Body outline drawing.

Simon (nearly 13) was referred because of temper outbursts, resulting in expulsion from school. In addition to tempers, this singleton child suffered from epilepsy and diabetes, and had been diagnosed as having Asperger’s syndrome.

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After the assessment session, Simon agreed to come and see me to ‘work on his anger’. During the first of three sessions I suggested we try the body outline drawing to see if we could locate where the anger came from. Long-term work was indicated for Simon and he attended for many months. As I got to know him and began to understand the disabilities he was suffering from, I said I could understand why he might get angry. I talked with his mother and himself about the rages and it became apparent that the ‘tantruming twos’ were still in evidence. Mother and son had a very close relationship, and since Simon’s expulsion from school, his mother was his constant companion and carer. I learnt that two was the age when Simon became seriously ill, and developed diabetes and subsequently epilepsy. I explained it was as if he had got stuck at a much younger emotional level and indeed this was represented in the images of his art work, which looked like that of a much younger child. I asked the family to bring in photographs of when Simon was little, around the time he became sick. These images proved a useful connection to the past. Then we returned to the body outline drawing from a previous session, when he explained that ‘a wire had become disconnected’. I encouraged him to lie down in his previous outline, breathe deeply and think about what needed repairing, on the inside. Simon became animated, then got up and looked for a knife ‘to cut himself open’. Using a plastic knife for clay modelling, he pretended to cut his stomach. I encouraged Simon to draw this on the body outline picture. He said ‘I think I need a new battery’, which I perceived as an insightful connection, given the difficulty with his energy-regulating organ, the pancreas. Simon drew a small battery at the body’s centre with a black and red crayon signifying the leads. The black wire had broken, he said, and needed an operation. Simon then enacted surgery in the doll’s house, which doubles as a hospital. He spent 20 minutes or so operating upon a small model figure to repair ‘the break’. He also noticed that ‘a couple of legs were broken, too’. I commented that people could see broken legs but not a broken pancreas. Simon also drew his heart above the battery. He asked how big it would be, and I said it was about the size of a fist, so he drew round his fist and thumb in red. He did this twice – once for a ‘heart that is OK’ and once for a ‘heart that is upset’ (the one screaming Ah aaaaah). Simon still has temper outbursts but they are not as frequent as they used to be. His mum feels they do not escalate like they did. Simon manages them

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well enough to maintain part-time attendance at a mainstream school, in a special educational unit.

Conclusion The process of art psychotherapy in combination with cognitive behavioural techniques gives children practical tools with which they can begin learning to control their temper. Creative methods enable children to visualise and work with tempers previously defying being named and tamed. The concept of the ‘toolbox’ helps children, young people and their families to learn how to mend broken tempers. Healing is facilitated through a multidisciplinary, family systems approach, of which art psychotherapy is a part. The ‘toolbox’ is more tangible than the magic wand but equally able to produce some transformations.

References HH the Dalai Lama. (1999) The Dalai Lama’s Book of Wisdom. London: HarperCollins Publishers. Liebmann, M. (2004) Art Therapy for Groups (second edition). London: Brunner–Routledge. Malcolm, R. (1992) ‘As if: the phenomenon of not learning.’ In R. Anderson (ed.) Clinical Lectures on Klein and Bion. London: Brunner–Routledge. McDonald, K. (1985) How to Meditate – A Practical Guide. London: Wisdom Publications. Sandström, C. I. (1983) The Psychology of Childhood and Adolescence. Aylesbury: Penguin. World Health Organization (WHO) (1990) International Classification of Diseases, 10th Edition. Classification of Mental and Behavioural Disorders: Clinical Descriptions and Diagnostic Guidelines. Geneva: World Health Organization.

Chapter 3

When Love is Absent, Anger Fills the Void: Children in Foster Care Elaine Holliday

Introduction I am an artist and art therapist with 20 years’ experience of working with children in foster care. For the past ten years I have practised as an art therapist with the Integrated Services Programme (ISP). This organisation was one of the pioneers of independent fostering in the UK. At ISP children and young people are carefully matched to a foster family and have access to the services of a multidisciplinary in-house team of social workers, therapists and teachers who are based within the organisation’s community centres. At ISP I am able to offer short- and long-term individual art therapy to children and young people. In 2003 I also joined Foster Care Associates (FCA), as a principal therapist. FCA is the largest independent fostering agency in the UK and specialises in placements for ‘hard to place’ children and young people. FCA provides an integrated approach to children and foster families, on a national scale. The FCA therapy service works closely with carers and with the whole system in understanding and identifying the specific needs of children. Both agencies work closely with local authorities and are regulated by the Care Standards Commission. In my work I meet children and families who have experienced disruption, separation and loss. I have come to respect that every stage of fostering carries difficulties, and that the task of fostering and of being fostered evokes powerful and potentially unbearable feelings – even when it is going well. In thinking about the impact of these feelings, I have come to understand the role that anger can play in protecting children in care, and the adults looking after them, from the sadness and fear of their situations. I am also aware that 58

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anger as an ongoing and unhealthy means of defence disables children and adults from forming sustainable relationships and enjoying life. This, in turn, creates further disruption and a repetitive pattern of loss. As a therapist, I recognise the importance of acknowledging and understanding the reasons behind the anger, in order to initiate positive change and growth. I have learnt to respect anger but not to feel powerless in the face of it. When working with children who have been referred to therapy because of their anger, I have acquired a confident belief that art therapy can offer children non-violent ways to express their feelings and to discover themselves as individuals worthy of love and good experiences. Where words have failed and physical hurt has occurred, imagery can offer a safe arena for expression and recovery. In order to be able to write this chapter, I began by speaking to one of the young people that I am working with at ISP. I explained to him the purpose of the book and what I wanted to say, and he generously gave me his permission and his trust. Karl’s story is presented here to offer insight and hope to others, and to raise awareness of the vulnerability of young people in care to the negative projections and fears of others.

Case study: ‘It doesn’t matter’ Karl (aged 12 years) was referred to me for art therapy because of his violent outbursts and aggression. At the time of his referral he was being restrained in school on a daily basis. Karl was hitting out at both teachers and his peers in what staff described as an indiscriminate manner. Karl was nearly six feet tall and of heavy build, and sometimes up to four adults would be called upon to remove him from the classroom. At ISP the art therapy facilities are based within the organisation’s independent schools, and the first time that I encountered Karl was when he was carried past the door to the therapy room by a group of education staff – closely followed by a small crowd of pupils looking on. Today, 18 months on, I look back to that moment and find myself reflecting upon the fact that the first time I saw Karl he was horizontal and screaming. He looked like a battering ram. It was a vivid scene of despair and humiliation that left me wondering what on earth was going on. It was as a direct result of this experience that I began to make enquiries to see if there was anything I could do to help. I started this process by taking into consideration the thoughts and feelings that the incident had evoked in me. I could already feel a rising anger and outrage in response to what I had seen and heard, but needed to be able to contain this as the first step in

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thinking about Karl’s emotional well-being and needs. I quickly discovered that a referral to therapy had been made but was as yet unallocated. My offer of help instigated Karl’s referral to art therapy and to me. I hoped that reaching out in this way, rather than waiting for a referral, would perhaps give others fresh hope. Karl’s behaviour had evoked strong feelings of failure and frustration in those working with him, and had created a belief that it was either impossible or would take something extraordinary to understand what was going on – or to suggest something that could make a difference. The level of anxiety among the whole team working with him was high. The situation was becoming unbearable. In this context it was crucial for therapy to establish itself as a complementary service, working alongside teachers, social workers and foster carers, acknowledging their feelings and all the difficulties. I did not want my contribution as a therapist to be seen as an opposing approach and be undermined. In actively seeking to work with Karl, I know that the school partly experienced my intervention as an act of defiance against them, and I am confident enough to admit that this played a part. Healthy outrage can be well-founded and is a necessary emotion. However, I realised that in order to help Karl I would need to be able to think about the feelings that had been provoked in me and that this, in turn, might help me to understand the anger and anxieties of others. Although I felt angry at seeing a child being ‘held’ rather than comforted, I also realised that Karl and the staff were all suffering, and no one had set out to be like this. There had to be another way. As Karl is in foster care, my next step was to meet his carers. I already had a pre-existing working relationship with this family and we met to discuss Karl in a context of mutual respect and trust. This made a positive difference to our subsequent ability to think together on his behalf. Karl’s carers were deeply concerned about what was happening at school. At home with them he was sensitive and thoughtful, and the carers described him as a gentle person. Although they had been given initial information that suggested Karl was aggressive, they had not observed this behaviour and were more aware of his fears and phobias. They felt angry with the school and had felt upset on the occasions when they had been called in to collect him after a violent episode. The carers felt that the school might be to blame. The tensions between the aspirations and hopes of the foster carers and the rules and expectations of the school had begun to create further conflicts and divisions in the system. The local authority was being blamed for its inaction and for its incomplete and potentially misleading information

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about Karl. ISP’s social workers and managers were in conflict with the school regarding the suitability of his education provision. The anger was spreading like a contagious disease. It was a daunting battlefield to offer to walk into, and it was important for me to acknowledge that there would be a lot of work to do outside the therapy room, and to check that I had the time and the capacity to engage in this on Karl’s behalf. As I prepared to meet Karl, I knew that my biggest challenge would be to work with the system around him and to build bridges with all the services involved in his care. The anger was stopping people from thinking, and Karl’s deeper needs were being neglected. In the middle of this storm I gathered information about Karl’s life and the circumstances that had led to him being taken into care. However, I found it hard to keep this information in my mind as my in-tray became inundated with daily incident reports describing his violent struggles in school. It seemed to me that these immediate crises served to protect Karl from the pain of his past experiences. In negotiation with staff I arranged to offer Karl four assessment sessions during school hours to see how he would respond to working with me in art therapy. From the very start he was keen to attend. The therapy room where we met was large and spacious and full of art materials. Furthermore, the room had been established for over ten years and I am sure that this makes a difference in offering children containment. The room gave a visual message that it could survive ‘challenging behaviour’ – it had stood the test of time. Karl sat quietly while I introduced myself and talked to him about art therapy; he was quick to grasp what I was saying and began to talk enthusiastically about all the things that he might like to do. Karl was full of imaginative ideas and I was aware of a shared feeling of excitement at the prospect of having time to make things. All this came in stark contrast to the reports that I had read, describing him as dangerous. From the beginning of our sessions, I was clear in telling Karl that therapy had been offered to him in response to the difficult time that he was having, as it was not right for him to be experiencing restraint and isolation. Karl replied to this by saying that it didn’t matter. As the first stage in helping him to develop his self-esteem, he needed to know that it did matter. In the first session Karl created a flat paper island and placed one pipe-cleaner person upon it. The island felt like a safe and peaceful place to be, but was the lone figure marooned and isolated? I made an intervention and placed another person on the island. In first hearing about Karl I had recognised my

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own desire to help him and I now continued this process by showing him visually that I could bear to join him (Figure 3.1).

Figure 3.1 The paper island.

Perhaps the island also provided a symbol for the space and the retreat that therapy offered Karl from the hostility that he felt within school. In his daily school life Karl was being overwhelmed by his anger and then physically overwhelmed by staff. Perhaps I had also intruded on him by changing the nature of his island. Through the imagery, Karl and I were beginning to explore the difference between feeling suppressed or neglected within a relationship, as opposed to feeling encouraged and embraced. From the start of the therapy it became a feature of our relationship for Karl to seek my approval and permission for everything that he was making. He put his own needs aside and asked me to choose things for him to do. Karl was repeatedly dismissive of his own ideas and disappointments. It didn’t matter, it didn’t matter…he didn’t matter. In response I encouraged him to see the session as a chance to explore and experiment, rather than feel

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there was a right or a wrong way to do something. (This helped me to put the same idea to staff.) I appealed to Karl’s suppressed sense of curiosity and playfulness. I showed him my trust in his ability to find his own ideas, and my faith in waiting with him demonstrated to him my genuine interest in what he might do or say. In my work I have come to value this approach as the most meaningful way to provide a fellow human being with attention that is emotionally satisfying and restorative – and I believe that this, in turn, helps to develop resilience and to promote good mental health. Symbolically, I had joined Karl on his island in order to give him my full attention and support. In the second session Karl made plaster casts of his hands. This enabled us to have exploratory conversations about how he used his hands to express his feelings. In his daily life Karl was hitting out with his fists. Art therapy was allowing him a new experience of using his hands – to explore materials and to make things rather than destroy them. After making and painting the plaster hands, Karl began work on a volcano. I made the recommendation to ISP and to the local authority that Karl should be initially offered one year of art therapy, with a view to monitoring this through the looked-after children review process.

The turbulent land In the first six months of art therapy Karl made several volcanoes (Figure 3.2). Each one was hewn from clay and formed on a wooden base. We had to negotiate the size of each model so that I could lift and store them safely. The task of transporting these heavy volcanoes brought humour and laughter into the sessions – some light relief that enabled Karl to experience a balanced range of feelings. The need for practicality in the image-making helped to provide containment for Karl’s exploration and messy play, and ensured that we worked at a bearable pace that would enable continuity of thought and feeling. In art therapy it was the volcanoes that were picked up and carried to a safe place rather than Karl. Making the volcanoes was exciting. The immediacy of the clay and of the paint that was poured into them – and spilled out of them – was completely engrossing for both therapist and child. Yet it seemed shocking that Karl and I were immersed together in such potentially destructive symbolism. Our therapeutic relationship, and the bonds and attachments that would lead to an ongoing and sustainable therapeutic alliance, were being forged in a symbolic world of flowing lava and turbulence. But this felt

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more alive and visceral than the flat paper island. Among many associations I found myself thinking about Surtsey, the Icelandic volcanic island that formed in between 1963 and 1967 and literally ‘burst into life’.

Figure 3.2 One of several volcanoes made by Karl.

At the end of these sessions, Karl sometimes created a recurring image of King Kong (Figure 3.3). This powerful portrait helped us to think about prejudice, and how misunderstanding, distress and fear can so quickly lead to aggression. During this phase of volcano-building, I was also fully engaged in negotiations with school staff, social workers and Karl’s carers, in seeking to maintain an open dialogue about the cause and treatment of Karl’s aggression. I had blown the whistle about the number of serious school incident reports involving Karl, and had suggested that this pattern of behaviour between staff and young people was in danger of becoming normalised. So I had to work hard to convince colleagues that I was there to be a helpful member of the team, included because I had a different perspective to offer, which might be useful. I promoted the idea that, in order to improve the situation for Karl, we each needed to be able to acknowledge our own part in

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Figure 3.3 King Kong.

the problem, and explore together, as a multidisciplinary team, the real things that were concerning us in working with him. At this time the tension among the whole team working with Karl was palpable. It was important for the organisation to be able to own this struggle and to have the capacity to know that ‘difference’ is information, and that it is difference that enables us to relate and grow. It was a welcome relief when the organisation established monthly professionals’ meetings that offered the opportunity for the adults to share their thinking. This move was crucial in preventing splitting and dysfunction within the team. The meetings gave time for colleagues to understand each others’ roles and to discuss their own angry feelings in relation to Karl and towards each other. The meetings allowed people to explore ideas and strategies and to draw from a multidisciplinary pool of skills and perspectives. Karl was aware that this thinking was happening on his behalf and knew that this was because we all wanted the situation to improve for him. We also wanted things to improve among ourselves. We struggled on. I don’t find it easy to explain to others what I have internalised in my understanding as a therapist. Much of my understanding has been gained

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through experience. Nor is it easy to talk across disciplines and professions and to find a shared working language. But as an artist I do know that being able to illustrate something well makes a difference. As I searched to find the words to explain to others the impact of angry projections and countertransference feelings, Karl spontaneously created a visual symbol that immediately expressed his experiences and enabled me to mediate on his behalf. This is described in the next section. From the inner world of therapy the external world became more visible and approachable.

The five volcanoes After making several single volcanoes, Karl began work on a land of volcanoes. This was constructed on an A2-sized board. He started by creating an outer wall (on the edge of the board) that would contain the lava flows. Four medium-sized volcanoes were built into this wall and filled with paint. Karl then tried to build a fifth volcano in the centre but, as he constructed it, the lava from the outer volcanoes poured into it. Because of this, the new volcano started to grow into a Vesuvius that could contain both its own lava and that of its surrounding group. It was the spontaneous making of this model and the unfolding scene that engrossed Karl rather than the completion of it. As I watched Karl forming the middle volcano, I found myself thinking about the outer wall as a representation of the anger that was all around him and flowing into him. This might be the anger of the other pupils, the anger and frustration of the staff as they carried him to the school’s ‘time-out room’, or the disagreements between the staff about why this was happening. It might even go back to the terrible moment when he was taken into care and the reasons within his own family that led to his separation from them. The middle volcano was trying to take shape and find a form in the midst of chaos. It was born out of a violent scene and was forced to be violent in return. I took time to reflect and ponder on this session and by the next week I felt eager to tell Karl what his art-making had enabled me to think about. I also asked Karl for his permission to take this story to the monthly professionals’ meeting to see if it would help others to think more broadly about his needs. Telling the story to the team changed the focus of the discussion and gave others permission to value their own personal stories about Karl and to

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learn from them. This was a change from talking about him only in terms of incident reports, recording sheets and potentially defensive practice. The team began to talk about the times when they had felt positive connections with him. Karl’s teacher spoke about a successful field trip to the seaside, during which he had enjoyed Karl’s enthusiasm and interest to learn about the rock pools and all the life within them. This had made him realise that Karl’s behaviour wasn’t localised to the school but specifically to the classroom setting. The experience had given him hope that things could be different. This was an important turning point. So, rather than singling out Karl for discussion, the dynamics of the whole class group (and the individuals within it) were considered. Before coming to ISP, Karl had not attended school for nearly a year and had spent much of his time alone and outside. He now found himself confined in a room with other children in foster care. Their presence provided a daily reminder of his personal situation and losses. He was overwhelmed and unable to hold himself together. When tensions arose within the classroom, Karl instinctively resorted to his previous strategy of going outside and being alone – but in the context of the school, this was ‘breaking a rule’ and staff intervened in his bids to escape. This inevitably led to conflict and physical struggles. Unable to walk away, Karl also hit back at pupils when they taunted him. Over a period of six months he gradually became the scapegoat for the group’s distress – just like the middle volcano. This realisation helped to lessen the tension and the fear of being singled out for blame, which had also been present in the multidisciplinary team of adults. Over the next months the number of violent incidents involving Karl began to lessen. At about this time his imagery also took a new direction. In one session the clay crater of a volcano transformed into an empty basket (Figure 3.4) and in later sessions Karl began to say that he did not know what to do. Having found a way to express and explore his anger, Karl was now faced with a feeling of emptiness. After being so active and busy together in the sessions, this new phase seemed shocking. My desire to rescue Karl from this void was even stronger than my initial desire to rescue him from the aggression that he was enduring in school. The feelings of loss and emptiness were excruciating. Karl was tempted to leave the sessions early and I was tempted to provide him with things to do.

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Figure 3.4 The empty basket.

The visual contrast of this imagery and conversation provoked my thinking. The comparison of these experiences enabled Karl and I to acknowledge the powerful role that anger had played in his life. The symbolism of the basket offered an opportunity for us to think about a search for satisfying things that could fill the space once occupied by his anger. More importantly, we began to consider the absence of good experiences and love that had created the empty feelings in the first place. Where the volcanoes had provided containment for the anger, the basket now offered containment for all that had been lost, as well as offering hope for all that could be gathered and found in the future. It was important that we shared this experience. Karl was not alone with his feelings. It took a while for Karl to find a new sense of direction in therapy, but, after a time, he asked if he could make kit aeroplanes and cars. The clay and paint were put aside and Karl spent many sessions carefully assembling tiny parts into delicate models. The models evoked conversations about travelling by air and land, and this offered further hope that Karl was now able to explore his world rather than defend himself against it. These complicated projects also allowed him to discover his ability to be patient and to invest in

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achieving something over time. The longevity of the art therapy (it can be available throughout a young person’s stay with ISP) took away the need to rush and lessened Karl’s anxiety to fix and finish things. In negotiation with me, Karl chose to take these models to show to teachers, friends and his carers. He used the models to engage warmly with others and it was encouraging to see the positive recognition and attention that this brought him. His enthusiasm led to other class members making models and even inspired the local model shop owner to offer to create a window display to celebrate their joint achievements. I began to feel genuine happiness for Karl. Where once I had confronted his teachers and the system around him, I now found myself looking forwards to meeting colleagues and exchanging stories and ideas. This made me realise the progress that he had made – that we had all made.

Everything matters At the time of writing, Karl is still attending therapy and this work is established as long term and ongoing. The empty basket that we once contemplated has been replaced by a hand-made model of an aircraft hangar big enough to store the things he is making. In his conversations Karl has begun asking questions about his past and can bear to think about the things that have happened to him. I was recently delighted to hear from the team that he had been asking teachers fundamental questions about birth and life. Karl has developed the self-esteem and confidence to be able to ask his questions and has the emotional capacity and sense of curiosity to want to learn. The phrase ‘It doesn’t matter’ no longer applies and, although there are still occasional incidents in school, Karl is less likely to be consumed by anger. Every now and again in therapy Karl and I go back and relive the pleasure of making the volcanoes. We share this story. This gives us further opportunity to retell and rework the survival of angry feelings and projections, and to think about them in the context of his whole life.

Anger is a communication of distress When working with Karl it was important for the whole team to think about the impact of anger and the way that it was affecting everyone in their attitudes and responses to each other and to him. This included thinking about what was missing or not happening when the anger became the dominant feeling – the absence of love, of being positively thought about

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and kept in mind, the loss of hope and good experiences, the loss of a united ‘family’ or group to belong to and feel a part of. In the therapy, the need to work with the presenting anger kept me from being able to think fully about the past and all that Karl had been through. This protected Karl from being close to the source of his vulnerability and pain and the loss of his family. With time, I was able to recognise this gap as useful information that indicated the depth of Karl’s pain and grief, rather than see it as a failure on my part. For many of us, anger is a thing to be swiftly dealt with and got rid of. No one wants to feel hurt. In the face of this it takes courage to pay attention to the impact and function of anger, and to learn from it. The easy route is to blame or punish the perceived instigator and so deny them the very things that will help them to recover. It also requires effort and commitment for a complex team of professionals working with a child in care, to make time to join up the different and often opposing perspectives about a child’s well-being and needs. I value the words of John Hills, family therapist, who speaks of the need for multidisciplinary teams to be able to ‘listen uncomfortably’ to each other (Hills 2005). Art therapy gave Karl the opportunity to be a potent and contributing part of the team with a unique story to offer. Instead of being a victim of his anger, he became part of the thinking process. This enabled him to emerge as an individual with specific needs. Working symbolically with image-making and art materials enabled Karl to draw safely on his ability to express himself visually and physically, and to experience this as a creative rather than a negative communication. I am very appreciative of all that I have gained from getting to know him and those working with him.

An everyday story about anger Karl’s story is not an extraordinary story but an everyday story for many young people in care. Conflicts and strong feelings happen in all cases of ‘looked-after’ children, and it is how we, as adults, take the responsibility to think about and bear these feelings that will make a difference. Fostering is born out of tragedy and in childcare it is easier to talk about young people’s behaviour rather than acknowledging our own difficult feelings towards the work and each other. Children in care who are acquiring a reputation for anger and aggression are in danger of experiencing isolation and punitive care throughout their lives, rather than being thought about as ‘poorly’ in terms of their mental health and emotional well-being.

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Art therapy can help to reframe the way in which we think about and approach anger, and may help children and adults to be active and creative in the process of recovery. In order to do so, this work needs to be recognised as a contribution that makes a difference over time rather than a single solution or fast remedy. The rewards are worth waiting for.

Reference Hills, J. (2005) Personal www.lspchildcare.org.uk

communication. ISP

meeting,

Kent,

UK.

September.

Chapter 4

Anger and Danger: Adolescents and Self-harm Sheila Knight

Introduction I am employed in an East Midlands NHS Trust to undertake risk assessments and consultations, and to provide an art psychotherapy service for children and young people who have self-harmed. The incidence of deliberate self-harm among children and adolescents has soared over the last 20 years (Mental Health Foundation 2003). Recent data from the Office of National Statistics indicates a prevalence rate for deliberate self-harm of 1.3 per cent and 2.1 per cent for 5–10- and 11–15-year-olds, respectively (Meltzer et al. 2001). In July 2004 the National Institute for Clinical Excellence (NICE) published guidance on the prevention and management of self-harm. Contained within this document are recommendations pertaining to the care and treatment of children and young people, aged 16 and under, who present to services. At the heart of these clinical guidelines is the recommendation that all children and young people who have self-harmed, irrespective of severity, should be admitted to a paediatric ward. The Child and Adolescent Mental Health Service (CAMHS) team should undertake assessment and provide consultation to the young person, their family and the paediatric team (NICE 2004, p.30). Moreover, the guidance development group strongly recommends that consideration be given to offering psychotherapy to young people who have self-harmed; in particular, to those who have done so on more than one occasion. I believe that art psychotherapy encourages children, adolescents and families to explore their potential for positive, creative development at a time in their lives when destructive and damaging behaviours are at their height. 72

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A significant sign Whilst wandering along the Clyde estuary in the mid-1980s I came across a piece of inspiring graffiti. Twenty years on I am still grateful to the anonymous person who presented such a meaningful image to me. Graffiti is often the art of young people, and the image that I encountered continues to be of help to the young people whom I meet on the hospital ward when I undertake risk assessments after a self-harm or overdose suicide attempt. The image was a warning sign guarding a rotten landing stage leading from the river’s edge out to where small boats could moor. You could step off the landing stage and be in the deep tidal river where basking sharks and seals may be seen on occasions. The staging was the worse for wear, planks were missing and the supports had sunk to a drunken angle. A barrier had been erected to keep passers-by and the public at large, safe from the potential risk of falling into the river. Metal railings and barbed wire stretched around the platform preventing anyone from entering the area. In the centre of this barrier was an official red metal sign with lettered instructions printed on it: DANGER KEEP OUT

Someone had come along with some red paint, painted over the letter ‘D’, so that the sign now read: ANGER KEEP OUT

It had not occurred to me before stumbling across this image how the letter ‘D’ was all that separated the two words: Danger and Anger. Yet the barbed wire and the dangerous platform leading into the undercurrents of a fast-flowing river, which could quickly sweep you out to the Atlantic Ocean, had created a powerful environment for these closely linked words to state their message. The fragment of time that I spent observing that image (Figure 4.1) has stayed with me and I have shared some of its poignant ripples with many of my clients. The setting for the warning sign is an integral aspect of the overall image for me. The platform’s appearance suggested that it could have been a victim of an angry, aggressive attack. The public warning sign is powerfully positioned, informing us that anger is present. The metal barrier and tangled wire have war-battle barbs threatening to tear at our flesh if we come too close to

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Figure 4.1 Anger – Keep Out.

engaging with the barricaded anger. The fast-flowing River Clyde surrounding the staging also indicates that, as well as accidentally falling into the deep waters, we may be swept away by the emotion and find ourselves in the depths at the mercy of the flow. The young people that I meet often tell me about the flow of their life and the powerful forces that led them to become submerged and adrift from solid ground. This public statement about anger and danger has been in my mind as a significant sign since encountering it as a piece of ‘uncommissioned community art’.

Anger and danger Anger appears to be an emotion that we would wish to be warned about, protected against and even have extracted or removed. Many routine referrals into our department state that ‘This child has a problem with anger, please provide anger management and help this child not to feel angry’. Young people and their families are often surprised when I reframe anger and highlight its positive aspects. If we feel anger it usually indicates that we care about something. If we do not care, then we would not be likely to feel anger and would not be ‘bothered’ about the incident or experience that had just

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occurred. Anger can be creative and can lead us to make positive changes in our lives, our environment and within society. The source of difficulty tends to arrive with the letter ‘D’ when anger transforms into Danger and they link together hand in hand. The ‘D’ can bring death, damage, destruction, difficulties and devastation into the experience, and although these aspects do not omit the potential for creativity, the risks to self and others become high. Separating these ‘D’ words from ‘danger’ so that ‘anger’ may be seen, heard and acknowledged safely is the concept that I often ask young self-harmers and their families to consider. The risk assessment on the hospital ward and the risk management follow-up appointment explore the particular details, events, circumstances and interactions that led to the self-harm and brought the ‘D’ words of death, damage and destruction into the young person’s life at that time. The tempestuous events tend to encourage the child, the family, or both, to engage in an ongoing therapeutic relationship. When I am considering a treatment plan for an adolescent or child who has self-harmed, I meet the family and discuss whether a cognitive approach or a psychotherapeutic service would be appropriate. I also ask if individual work, family work, parent–child work or group work would seem most helpful. The response varies, and the extent of the emotions and the volume of anger and danger tend to favour a particular type of service. Many of the young people choose to engage in individual art psychotherapy, partly because they have met me at a crucial time of crisis, but, as I also receive referrals from my colleagues in the risk assessment service, it appears that art psychotherapy is something that is appealing to children and families. Each story, by its nature, is unique. However, I am able to pick out a few themes that seem to arise in families, parents, children, young people and their peer groups at this time of developmental change. Becoming a parent is a major event and a couple’s relationship may have altered greatly. The pattern of interactions between the couple and the child or children may not be how the individuals imagined life to be. Separation and divorce are common, and children often hold and express many of the emotions that are felt within the family. Life may bring many situations to challenge children and their parents. Adolescence is sometimes described as a transitional stage or phase of development from child to adult. If I consider the process in the context of an adolescent within their family, I suggest that the family system is transforming along with the adolescent, and the changes, growth and

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developments which occur create an emotional charge for all family members. The roles that have been developed as the family has formed tend to be challenged and questioned by family members and extended family, for example household rules need to be re-negotiated to take account of independence and responsibility. Parents may re-assess themselves, their ambitions and time commitments. The parents may wish to create time for themselves. The male or female roles and relationships within the family may change dramatically as adolescents create and take action in relation to their own sexual identity. Living spaces may alter and rooms may change their purpose or use. Sometimes the household may appear extremely full; that is, accommodating the adolescent and friends and intimate partnerships within the house on occasions, yet, at other times, it may seem empty and not in use. The hopes and fears for the future also loom in sight as adolescent and family look on the past and the childhood experiences of the adolescent and also look forwards to what may occur and develop. Family art therapy can be a service that assists all family members to explore together and communicate these transitions in a creative and often humorous yet meaningful way. Peer group pressure can be intense, and the move into independence often begins with peer group friendships and intimacies. However, competitiveness, isolation, alienation and changing loyalties can lead to jealousy, loss, anger, feelings of betrayal and/or general emotional turmoil – especially when bullying and threats bring the ‘D’ words into relationships. Emerging mental health conditions of depression, personality disorder and schizophrenia may also occur in adolescence, along with the complexities of a developing sense of self and peer group responses to behaviour and thoughts. Group art psychotherapy may be attractive to a young person who may want other adolescents to witness their experiences and creativity. Creative group interactions and sharing generate healing. Many families may have suffered traumas, loss, bereavement, divorce or separation and re-forming or extending their families. Parent–child therapy can create a potential space to explore life events. The anger that is so often needing to be acknowledged and given a creative space may be facilitated by art psychotherapy; if it is heard and responded to, then danger and all the other ‘D’ words are less likely to be actioned, so that the all-too-familiar devastating outcomes may creatively be changed.

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I have chosen four vignettes from case examples that have enabled me to see how anger and danger are so closely linked together.

Jane Two swimmers wrestled on the spar Until the morning sun. When one turned smiling to the land, Oh God, the other one! The stray ships, passing, Spied a face Upon the water borne With eyes in death still begging raised And hands beseeching thrown. (Emily Dickinson 1830–1886) (From Selected Poems of Emily Dickinson. By permission of Pearson Education.)

Jane, an observant and sensitive 16-year-old, was known locally for holding out a helping hand when her peers found themselves struggling with emotional turmoil and whirlpools. When a fellow pupil turned her attack on to Jane, she discovered that hers was the only helping hand available. Jane was disappointed with her inability to help herself and she reached for tablets. I met Jane and her family on the hospital’s paediatric ward and they chose to receive family appointments. Jane gave her mum permission to hand me a selection of her poems and for me to read them aloud. One poem spoke of her pain and the entanglement between the bully and herself, the bullied. Hello Hello, do you remember me? You made my life a misery, You picked on other girls until they ran, You stabbed at me until I broke, You blinded me until I woke, You thought I wasn’t human, Here I am. Hello, do you think of me? You made my days melancholy,

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But still I held my ground and watched it quake, You pulled my hair until it throbbed, You laughed at me – I never sobbed, You thought I was a fool, Now I’m awake. Hello, do you remember me? I watched you joke so bitterly, You thought I was a goner when I ran, They say I’ve changed; I guess it’s true, ’Cause now I’m free to laugh at you, You thought I was afraid, But here I am.

Jane’s mum cried as she mused on the strains of her daughter’s poems. She voiced her concerns that she may have inadvertently pressured Jane into attempting to achieve a mother’s dream for her daughter. Jane’s mum hoped that Jane would be able to do all the things that she (mum) had not had the opportunities to do, such as be outgoing, to travel, to go to university and to have an enjoyable, meaningful job that paid good money. Jane’s close encounter with the desire for death and the emotional aftermath and distress led to self-blame and guilt within the family. The emotions rendered each person self-sacrificing, inviting dangerous deeds. Jane’s father was angered by violence, wars and aggression, and wished to protect his children and wife from such things by providing humour and fun in order to keep the anger away. The family fathomed that depression also lay beneath the need for light-heartedness. Depression was a condition that the extended family suffered from and I felt the danger that this held for them. It seemed appropriate to show Jane and her family the image of ‘danger and anger’. The altered warning sign image combines a delightful quality of humour and wit with the perilous dangers of anger. Jane’s skill and love of the written word, and her father’s sense of humour, encouraged the family to perceive the changed image in a meaningful way and to consider how to be creative with anger. We were all moved by Jane’s eloquence and ability to write about a subject that held so much emotion for herself, her family, her peers and humanity. Jane’s poems were published in the school’s magazine and a ‘circle of friends’ programme was initiated to provide a life-belt for combating the isolation that tends to be a component of bullied and bullying interactions.

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Positive actions had emerged from Jane’s emergency. Sharing the poems dissolved the ‘D’ letter, transposing danger into anger and enabling care to be seen and felt. The Clyde-side image had been a catalyst in this process. ‘poetic justice’ indeed!

Joan Joan was 14 years old and determined to die, finding no religion, rhyme nor reason to continue. Her young life felt like torture and she saw well-meaning professionals as misguided and cruel in their belief that her life was worth living. Joan took tablets on several occasions and was once taken into the intensive care unit as the hospital medical staff counteracted the poisoning potions that she had ingested. Joan chose to receive an individual art psychotherapy service where she was able to explore and consider the emptiness and lack of meaning in her life. One image that seemed potent was of a clay figure filled with red paint. When the figure was cut into, the red paint seeped and flowed out. This linked in with the fact that Joan used to cut and burn herself when stress and strain became overwhelming. Over time rage, resentment and fury forced its pathway through social etiquette into the centre of the family. Joan’s family was brimming with rancour and the home had been, and was, an emotionally dangerous place. Joan no longer lived with her family, choosing to have access with them and a space or place of her own. She managed to distance herself from the anger and anguish of the household. Joan was able to recognise that her dangerous actions and intent were related to her own and her family’s anger. The ‘D’ word of death had become dislodged from danger and she no longer needed to be the ‘angel of anger’ for her family as they became able to vocalise their own emotions, and Joan was able to live her own life.

Jules Jules was 17 years old, with a history of self-harming in response to intense fears of rejection and abandonment. She attended individual art psychotherapy and created a pattern (Figure 4.2) that related to her relationships and friendships. She described the pattern as repetitive in that she responded to many of her friends in the same manner, with situations repeating over and over again. Most people respond to fear with a survival reaction known as the ‘fight or flight’ mechanism. Jules discovered this mechanism when she

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Figure 4.2 Jules: Pattern.

feared that a friend was rejecting her or may have wished to abandon or leave her. At such times Jules tried to restrict the person from leaving the building, thus preventing them from fleeing – and then fought with herself by cutting or taking tablets. She also hoped to gain their care and attention by her actions. She was aware that this sequence of events was not helpful for her or her friends. When Jules explored her fear she unearthed anger. The painted pattern shows love and the joy of friendship surrounded by circles of anger and fear of losing the relationships that she held so dear to her heart. The anger and fear that her friends might leave her had become dangerous, as Jules harmed and punished herself as well as restricting and scaring her friends. Jules created a ‘First Aid’ box in the form of a piece of card to keep in her purse for emergencies. It did not contain sticking plasters and bandages, but visual symbols to remind her of the triggers and danger points that might start off her anger and fear, turning it into dangerous behaviour. The First Aid box creation helped her to explain to her friends what she felt and how she was trying to avoid responding in her usual destructive manner. It enabled Jules to prevent the ‘D’ words of damage, destruction and death from attaching themselves to her anger and was pivotal in learning to avoid her previous dangerous pattern.

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Jules continued to work on her life experiences, celebrating her gifts, skills and achievements, which she had previously struggled to acknowledge. Her confidence grew and her relationships began to develop much more positively.

James and his father (Mr X) James’ parents had separated and his mother had a new partner. James had become an older brother to the children produced by the couple. James lived with his mother and had access visits with his birth-father – so he had two ‘dads’ – a stepfather he lived with and a birth-father he visited. James was aware of stories and some details of his birth-father’s history as a young man, which did not promote a sense of security for James. Mr X was concerned that his son, James, now aged seven, seemed frightened of him and had sensibly informed his mother and appropriate adults of this. James and his father attended for parent–child art psychotherapy – James was delighted at the prospect of engaging in art and play with his father. Much fun and creative communication occurred between father and son. James drew a picture of a car (Figure 4.3), one of his father (Figure 4.4) and one of himself (Figure 4.5). James said he was frightened of his father swearing at other car drivers when they made annoying manoeuvres. He thought his dad might get into a fight or that someone, maybe his dad, might crash a car and die. Mr X agreed that he did not have patience with car drivers and that his anger might become dangerous. He told James that he would keep his thoughts to himself and not shout or behave aggressively when car drivers upset him. James told his dad that he would not mind if he muttered under his breath, but was pleased that he would try to stop shouting. They were able to talk about a recent incident, when James had run across the road without looking and his dad had grabbed him, which had frightened James. Mr X told James that he had grabbed his arm because he was frightened that James would get hurt or even killed. James had known his father was angry, but had not realised that it was because he loved and cared for James so much that the thought of James being hurt had scared him. James said he did not know that his dad could feel scared. He thought that only he felt scared and that dad only felt angry. James agreed that he would try to remember not to run across the road without looking. James and his dad chose to play and draw together more often as they valued the time when they could communicate their feelings and emotions calmly and

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Figure 4.3 James: A car.

Figure 4.4 James: My dad.

Figure 4.5 James: Me.

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creatively. The ‘D’ words had been dispelled and ‘danger’ had become ‘anger’, and this process itself had provided the expression of safety and love, enabling a positive relationship to develop.

Conclusion Many children and young people who attend the Accident & Emergency department after a self-harm or suicide attempt are indifferent to danger. Family and friends are often angry as they love and care for them. Anger often emerges from this situation, and, if an art psychotherapy service is available, the anger can be heard as a positive, involving emotion and lead to a separation from the danger. The warning sign on the Clyde-side jetty informed us of danger. The graffiti artist transformed it into anger, suggesting that anger should also keep out as it can become dangerous. However, if we can embrace anger it contains the potential for creative care and change. The individuals who saw anger in danger have assisted my work and thereby many children, young people and families, whom I have had the honour of meeting during my 20-odd years of working as an art therapist. I wish to celebrate and to thank them. I stepped from plank to plank, A slow and cautious way; The stars about my head I felt, About my feet the sea. I knew not but the next Would be my final inch. This gave me that precarious gait Some call experience. (Emily Dickinson 1830–1886) (From Selected Poems of Emily Dickinson. By permission of Pearson Education.)

Acknowledgements Sadly, Sheila Knight died unexpectedly in October 2006. Thanks are due to her partner, Neil, to her CAMHS team and to Jessica Kingsley Publishers for their help in finalising the chapter for publication as Sheila would have wished.

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References Emily Dickinson (1830–1886) Poem 26 and Poem 120. In J. Reeves (ed.) Selected Poems of Emily Dickinson. Oxford: Pearson Education, p.14 and p.75. Meltzer, H., Harrington, R., Goodman, R. and Jenkins, R. (2001) Children and Adolescents Who Try to Harm, Hurt or Kill Themselves: A Report of Further Analysis from the National Survey of the Mental Health of Children and Adolescents in Great Britain in 1999. London: HMSO, National Statistical Publications. Mental Health Foundation (2003) ‘Deliberate self-harm among children and young people.’ Updates 4, 1–4. National Institute of Clinical Excellence (NICE) (2004) Self-harm: The Short-term Physical and Psychological Management and Secondary Prevention of Self-harm in Primary and Secondary Care. London: NICE.

Part II

Offenders

Chapter 5

Inside-out/Outside-in: Art Therapy with Young Male Offenders in Prison Sue Pittam

Introduction When a young person comes into prison they bring with them their problems from the outside world. Anger is displayed outwardly as violent and explosive, or is quietly internalised. This chapter examines the dynamics of both. The client group consists of males aged 18–21 years, who are on remand or serving sentences in a large young offender institution. Research suggests that as many as 25 per cent of the teenage population in the UK are engaged in criminal activity (BBC 2005). Anger is an important factor behind many crimes committed by young offenders. Art therapy can be used to work on this strong emotion, and can help clients to become more reasonable and responsible young people. This work does not condone the offence, but looks at the reasons behind it. Aggressive and violent crimes are often the result of acting out feelings of anger, which, in turn, often emerge from the trauma of loss, deprivation or any abuse which damages the individual’s ability to form satisfactory relationships (Zulueta 1996). Insufficient emotional care during childhood inhibits social behaviour and prevents the development of empathy towards others. Recent neurophysiology research explains functions of the brain that were not previously fully understood, and has shown that emotional attachment is an essential part of brain development. Art therapy can help to redevelop this process. The majority of young prisoners have experienced a lack or loss of attachment, which is the cause of underdeveloped emotions, the earliest being anger, fear and anxiety. When a young offender is imprisoned, the loss 87

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of their freedom affects other losses and this is a main cause of angry behaviour which prison staff have to manage.

‘Inside’ life My place of work is a large medium-secure young offender institution holding about 800 inmates. The prisoners are either on remand or are serving sentences of up to four years. Most inmates are released after completing half of their sentence. The young offender institution was built in the 1970s. It is situated in a suburban area and is spread over several acres of land surrounded by a large metal fence. Built of red brick and flat-roofed, the prison is divided into ten large units, four storeys high, built separately and linked by long corridors. These are punctuated by barred gates that close with the sound of banging metal and the rattle of keys. Various workshops and departments which provide services make up the rest of the complex. Between the buildings are large areas of grass, with sports fields behind. The mission statement for the young offender institution describes it as a place designed to rehabilitate and provide training. Yet a tension exists between the staff who regard prison as a place for punishment and those who work to assist prisoners to become more responsible and accountable young people. Improvements have been made during the time I have worked here, but it is slow. Staff need to beware of becoming tired and burnt out, which can lead to a punitive attitude in an effort to survive. The institution is a noisy and boisterous place, but young offenders can also spend many hours of boredom behind locked doors. When people are placed in prison their anger is often compounded. The loss of their freedom affects on other losses not yet resolved. Being separated from ‘outside life’ also aggravates social and family problems. Prison is a containing place that removes or limits access to drugs and alcohol. Most acquisitive crime is related to drugs, commonly used as part of teenage peer group activity. For some users drugs or alcohol block out painful memories and unresolved relationships. Therapy can be used effectively during time in prison to address these issues. Art therapy takes place within the healthcare centre. This provides both general and mental healthcare to all prisoners and is part of an NHS Primary Care Trust. It is staffed by nurses, medical officers, pharmacists and clerical staff. Visiting specialists include psychiatrists and general practitioners (GPs). Nursing staff are qualified in the areas of general, psychiatric or

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learning difficulties. An NHS mental health in-reach team works within the prison, doing mental health assessments, providing continuing support and liaising with outside agencies to continue care on release. Since the closure of large psychiatric hospitals there has been an increase in mental health cases entering the prison system. The art therapy service is an integral part of healthcare. I am the only art psychotherapist here and work as a member of a supportive team. Most clients are referred by the nursing or medical staff. Referrals also come from drug support workers, psychologists and the sentence planning department. On arrival, all prisoners go through an induction programme and health assessment to enable them to settle to ‘inside’ life. As with all experiences of life, change brings insecurity. Those who need extra support, maybe to prevent self-harm, are looked after by primary care nurses visiting prison units. If extra input is needed and there is a background history which needs addressing, a referral is made to art therapy. A great deal of my work is concerned with cases of abuse (emotional, physical or sexual) and bereavement. Most of these involve working to dispel anger in various forms. Alongside this is the importance of improving self-esteem and confidence. Clients are brought to the outpatient department for an art therapy appointment. The room I use is spacious, it is top-lit so feels private, and has some large green plants that give it a pleasant feel. Working in a prison, the security department needs to know that safe practice takes place, so no sharp metal tools are used. Plastic modelling tools and knives are available. Clay models that clients wish to keep are given to them when they leave prison. My experience has been that the art therapy area is respected and stays safe. To achieve therapeutic security and containment, it is important to have good relations with the prison security department. With young offenders I have found that individual work is most 1 effective (unless the prison has a therapeutic community, when group work may be advantageous). On their own, offenders drop their ‘street-cred’ and look at what matters, without having to worry about confidentiality or being afraid to show emotion. Young offender institutions are places where revealing fears and vulnerability can put inmates at a disadvantage. Beneath anger there invariably lies hurt and pain. By giving the young prisoner a space to explore his feelings in therapy, there is a good opportunity to aid

1

Some prisons have a wing that operates as a therapeutic community, in which most of the work is done in groups.

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healing and reduce angry behaviour. This can, in turn, reduce offending behaviour. As Goleman states (1996, p.210), ‘The act of drawing is itself therapeutic, beginning the process of mastering the trauma’ and, ‘Even the most deeply planted habits of the heart learned in childhood can be reshaped. Emotional learning is life-long.’

Aspects of art therapy and anger Art therapy offers a triangular relationship between the therapist, the client and the image. The art product is a tangible and concrete product on which the client can place feelings safely, including anger. This gives a unique way of working that can be equally accessed by all levels of ability, and is very useful to enable verbal expression. Neurophysiology helps to explain the clinical workings of the brain and part of the process that takes place using art therapy. Emotional development occurs in the limbic centre of the brain. This area is sited in the right hemisphere where a group of linked structures develop social and emotional intelligence. The amygdala, a very small organ in the forebrain, is important for emotional response and emotional memory, and it also responds to threats or impulses. It is suggested that the amygdala may be the place where anger first sparks (Goleman 1996). It is thought that the orbitofrontal area stores more refined forms of anger, such as sadness, shame and guilt (Gerhardt 2004). The hippocampus is a structure of the subcortex that regulates emotions, links words to feelings and is important in both learning and memory. Lack of development and trauma in the limbic area of the left brain prevents the passage of information between the two hemispheres. This prevents emotional experience being expressed in language (Schore 1994). Angry behaviour is often the result of not being able to articulate this emotional experience, and art therapy may help by enabling communication between the hemispheres. The creative process addresses this by, first, working on the right hemisphere of the brain. The therapy then facilitates links to the language and long-term memory on the left side of the brain. Clients become able to access feelings and to explain how they feel. It is this process that is hindered in cases of post-traumatic stress disorder (PTSD), when the trauma continues to trouble the client. Psychological trauma can also reduce the ability to learn. When working with abused children, in another post, I noticed that in many cases the

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reading age of the child halted at the time of the abuse. Then, when they engaged in therapy, they were able to connect with learning again. Similarly, when a prisoner’s chaotic, angry and upset behaviour is addressed in therapy, he will settle and eventually be able to learn effectively. Examples of this are given in the case histories. Some clients give out anger in large doses as a defence to keep people away. This feels unsafe to the recipients and often to the angry person. After an angry outburst, a young person frequently regrets the outcome. The image can contain this anger and feel a safe place to put angry or violent thoughts. It will reflect feelings back to the client so that they can eventually understand and articulate them. The therapist works between the client and the image in understanding the transference of feelings, allowing expression and withstanding the strong emotions of the client. The model or picture is confidential and kept safe for the client in the art therapy space. Containment and boundaries are paramount, these provide the safe feeling achieved in the therapeutic setting. Psychotherapy does not have to be long-term to be beneficial, short-term work is also effective. Young people can respond quickly to treatment and it can be helpful for them to know when the therapy will end. This is particularly important in cases of sexual abuse, as when the abuse occurs the victim does not know when it will end. Whilst revisiting the abuse during therapy, it is helpful to know when it will finish. A set of sessions may be agreed initially, with a further number offered if more work is needed. Prisons are ‘temporary’ places and transfers elsewhere, or court arrangements, can be frustrating. This can be alleviated by looking at the remand period or length of sentence, then deciding what can be realistically offered within that time. For each new client I use a simple self-evaluation form containing ten questions (Figure 5.1). This was devised and piloted using my research experience, the assistance of professionals and also the client group. This information has been collected over a period of six years. To arrive at an overall score, I assign a score to each column: the ‘Little or never’ column scores 1, ‘Sometimes’ scores 2 and ‘Often’ scores 3. The average initial score for clients is 23.2 and the average score on finishing art therapy is 16.2. This is a significant reduction of approximately one-third in anxiety, anger and negative self-image. The clients find it gratifying to see the change when they look at the two forms side by side at the final session (they are shown the initial form again, after completing

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Art Therapy INITIAL Evaluation Form Healthcare Centre Date: Name:

Release date: Please tick below Little or never

Sometimes

Often

1. It is hard to talk. 2. I feel alone. 3. I feel angry. 4. The past upsets me. 5. I worry about things. 6. I can’t sleep. 7. I need help to sort my problems out. 8. I feel like harming myself. 9. I want to end my life. 10. I feel there is no future. I would like art therapy to help me with ······························································································································································ ······························································································································································ ······························································································································································ ······························································································································································ ······························································································································································ ······························································································································································ ······························································································································································ ······························································································································································ ······························································································································································

Figure 5.1 Art therapy initial evaluation form.

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the final self-evaluation). There is space on the initial form for the client to state the help they feel they need, and on the final form to write how they have found art therapy. Some clients use this space, which is not evaluated – many comment on how it has helped their problems with anger. This evaluation produces a client-based form of evidence which may be useful for clinical audits of our work. For art therapy this initial evaluation is a very basic summary of the work needed and is used only as a rough judgement of what could happen in the sessions. It does not, of course, give any indication of the nuances and layers of material that may be processed during the course of therapy.

Case studies I have chosen two contrasting case studies to discuss my work. Dan had a history of anger displayed outwardly, whereas Sean kept his anger bottled up inside until he became extremely stressed. Both names and some case details have been changed to maintain confidentiality. Once engaged in therapy, their anger reduced, they were able to settle down in prison, to reduce or stop self-harming and learn new skills.

Dan: anger and sexual abuse Dan, aged 19, was on remand for grievous bodily harm, having assaulted and severely wounded a man. He was under the influence of alcohol at the time, and did not know the person he attacked. Dan was referred for art therapy as he was having difficulty settling in the prison, was involved in fights and had a history of self-harm. He was experiencing nightmares and intrusive thoughts during the day. The psychiatrist had given a diagnosis of PTSD. At the first session he presented as angry and surly, having fresh cuts to his forearm and swollen knuckles on his hands from hitting the walls of his cell in both anger and frustration. Dan had been taken into care as a young child. Then, after returning home, he had been sexually abused by an uncle between the ages of seven and ten. While the abuse was taking place, Dan’s behaviour became, as he expressed it: ‘wild, no one could control me’. Clients who have experienced sexual abuse have many losses. These include the loss of privacy, childhood, self-esteem, confidence and many other individual losses. The experience leaves them frightened, they are often threatened not to tell anyone, and if they do, they may not be believed. At the age of 11, Dan was taken back into

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care and at 14 he disclosed the abuse. Although he gave evidence to the police, it was not enough to convict the perpetrator. Not being believed, or the abuser getting away with the offence, causes extreme anger in the abused. It was at this time that Dan began to cut himself, drink alcohol and use drugs. At the initial session of art therapy Dan was keen to use the art materials, telling me that he used to be good at art but had forgotten how to do it. He chose a large sheet of white paper and proceeded to cover it with grey paint. Eventually this took the form of a seascape, and by introducing black paint, the clouds become blacker and the sea stormier. He worked with energy, pressing hard on the paper. His surly mood softened as the painting progressed. Few words were spoken as Dan put all his effort and concentration into the image (Figure 5.2). During the second session Dan added raindrops beneath the thunder clouds. He spent a long time placing them, crouching over his work, and transferred to me a very sad feeling. At a later stage when reviewing the work, he was able to articulate that the rain was symbolic of tears and the ships tossed about on the rough waves expressed how he felt at the

Figure 5.2 Dan: Stormy sea.

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beginning of therapy. The submarine represented the fear of the unknown, of abuse, and the fear felt at the time in prison ahead of him (Figure 5.2). Dan’s next image, of buildings on fire (Figure 5.3), was a direct way of expressing anger, fear and horror of the abuse. Vivid red and orange pastel was coloured onto purple paper. Dan thought it was his fault that he had been abused. It is the role of the therapist to correct this distorted view. It was also possible to explain that his ‘wild’ behaviour as a child was a result of distress, and not being understood at the time. It was at this stage in art therapy that Dan realised that the person he had wounded had some physical characteristics of the uncle who had abused him. At the time he was unaware of this, simply feeling driven by anger and revenge. Dan always showed remorse and took responsibility for his actions.

Figure 5.3 Dan: Buildings on fire.

By the fifth session of art therapy, Dan had stopped self-harming and his nightmares had subsided. On his unit he was building up points for good behaviour, which were awarded privileges such as more social time out of his cell. He was also hoping to be given a job that would give him a small wage. When anger reduces it can leave an ‘empty’ feeling and the person needs an

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interest or an activity to fill the space. In therapy it requires help to accept how it feels to be less angry and to get in touch with a more relaxed feeling of self. Dan showed this in his next piece of work. He changed to using clay, which excited him as he told me he had not used it since school. Playfully, Dan created a mountain scene on a piece of board. In the centre of this he painted a blue, smooth lake, quite unlike the stormy sea of the first image. Eventually he shared with me that it was a happy holiday that he had been on with a youth group. He stored this away carefully and inspected it with satisfaction on arrival at following sessions. It was at this stage that Dan enrolled on a City & Guilds vocational course, finding himself able to learn new skills. In the next sessions, he replicated the lake in blue and green paint on paper. Images that sustain good memories can often appear after reparative work has been undertaken. Once the anger has been addressed, and the pain acknowledged, the image work can move to a stage that is both soothing and healing. It is also a reflection of the psychological comfort found within the therapeutic setting. At our final meeting after 12 sessions, we reviewed his time in art therapy. Dan told me that he ‘had got his drawing back’. By this, Dan meant that, because he was not banging his fists against the walls in anger, the healed hands enabled him to draw. Zulueta (1993, p.76) shows in her work that there is a ‘strong correlation between loss, as a form of deprivation, and trauma and violent behaviour’. If the pain of the loss is addressed in therapy, then the behaviour of the client will alter. This case history has elements of many whom I deal with. The loss of freedom on entering prison affects clients’ experience of previous loss and abuse. Many of them disclose sexual abuse for the first time while in prison, and many histories can show the connection between the abuse and the offence.

Sean: anger and physical abuse Sean was a quiet young man who internalised his anger. However, when he was threatened or provoked in prison, his anger surfaced and male staff saw him as dangerous, with unpredictable, violent behaviour. Unit staff felt he might hurt them and were cautious in handling him. He was serving a three-year sentence for attempted armed robbery, using a ball-bearing gun. He had made a serious attempt to self-harm and had reacted violently when

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prison staff intervened. At the initial assessment for art therapy he presented as a cowed, quiet and sensitive 18-year-old. Sean began in the first session by making a model of a rhinoceros head, a very small one, delicately shaped. He informed me that the animal has pads of fat for protection, but Sean’s model showed only the head, and no fat. In the second session he painted it silver in a quiet thoughtful manner and gave the head a rather shy smile (Figure 5.4).

Figure 5.4 Sean: Rhinoceros head (left) and whole rhinoceros encased in duck (right).

Sean then moved to the sand-tray in the room to sift the sand and let it run through his fingers. Sean asked me about how the work was looked after, testing safety and confidentiality. In the third session, Sean made an even smaller model of a rhinoceros, this time the whole animal. It was tiny, about five centimetres long, and not too well joined at the limbs. As Sean began to paint it, bits fell off and needed glue, reflecting his own fragility. As he attempted to repair it, he disclosed that his father used to beat him when he was very small, until he became a teenager. His mother was also beaten by his dad. On one occasion his father attacked his mum with a knife. Sean phoned

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the police and when they arrived, both parents denied anything had happened. This had left Sean feeling frightened, confused and upset. It was Sean’s first time in prison and, fearing hurt, he had projected his angry and frightened feelings on to the male prison officers. Physical abuse is a crime in itself. Sean was kept from telling anyone by threats of social services taking him away. If children attack those on whom they are dependent, they believe they may be removed from their perceived source of survival (Cairns 2002, p.85). The model of the small falling-apart rhino was later encased in clay by Sean to make a very upright duck. It felt important that the duck did not fall over and Sean asked me to help him make the model stable. We found a wooden stick to support the model within the clay. The duck has a helmet to protect its head and also a gun laid at its feet (see above Figure 5.4, right). The encasing of the rhinoceros into the duck helped Sean to feel stronger as art therapy continued. By this time Sean had begun to understand that the male prison staff were not going to hurt him and he began to settle better on his unit. Self-harm reduced, and he started education classes and began a computer course. It became apparent that the robbery Sean attempted was done at a time of trouble and upset at home. He felt shame at his offence and also anger at feeling unwanted, as his mother and her partner did not want him living at home. Sean was enraged at the treatment he had endured from his father. He had survived by keeping the anger inside and believing himself to be bad. As a teenager he had begun to cut himself as a way to relieve the tension. Split-off feelings protect against loss of love and are of great importance in the understanding of human violence (Zulueta 1993, p.130). Sean was fond of animals and had found solace in the family dog during his childhood. This pet featured in much of his work – he did both a painting and a model of the dog and was pleased with what he created. During this time Sean’s self-esteem and confidence gradually improved both in art therapy and outside. He used the sessions to express his anger at the way his father had beaten him – he had scars to remind him of such unhappy and frightening years. The main purpose of the therapy was to provide Sean with a ‘“good enough” attachment relationship to help him to rediscover that which was helplessly endured and then defensively “split off ” in order to survive’ (Zulueta 1996, p.181). He became interested in watercolour painting, the delicate layers of translucent paint reflecting his feelings.

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Often, he would return to the sand-tray to smooth or filter the sand as he quietly thought things through. Towards the end of his sentence Sean began to worry about life after release. Many contacts were made with probation and the local mental health team to continue support work after discharge. He was released to go into hostel accommodation, which was not ideal. Nevertheless, six months after leaving prison the In-Reach team heard he was doing well. In summary, Sean’s internalised anger had erupted once at the beginning of his sentence. As staff learned about his past, they were able to understand his behaviour. Art therapy allowed him to disclose his abuse and work through his anger that had been internalised for many years.

Outside social factors for young offenders There have been a number of studies concerning the social and psychological background which predisposes to offending behaviour. Evidence shows that neglect, rejection and a lack of affection from early days can contribute. Good attachment takes place when the newborn child has a responsive and affectionate carer. But a baby who does not receive emotional communication, or experiences erratic and stressful situations, will not develop correct growth. The child who does not form a successful attachment will show outward signs of aggression and rage, or become unresponsive and clinically detached (Bowlby 1988; Cairns 2002; Zulueta 1996). Physical abuse has a damaging effect and prevents both language and learning development. Poor supervision is also a main factor in delinquent behaviour, which often increases as adolescence is reached (Hollin and Howells 1996). The teenage years are a mixture of wanting independence whilst growing away from childhood, causing many tensions between parents and offspring. Parents do not intentionally harm children. Harm is often caused by their own poor parental experience, the difficulties in raising children, socio-economic reasons or situations such as post-natal depression. Children who are adopted or fostered and have experiences of care situations will be more likely to have unresolved issues concerning their past history. Parental separation affects young people, often causing confused and angry feelings when parents acquire new relationships. If the main carer is able to show affection and provide good supervision, then offending behaviour is less likely to happen.

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Parental aggression at home can lead to both violent and non-violent crime in the offspring. This can include children experiencing physical abuse themselves or witnessing violence to others. Some offenders copy the angry behaviour of a parent. However, I find that many of those who witness violence as a child find it so frightening and disempowering, that they keep their anger locked tightly inside. The anger gets suppressed, escaping only if severely provoked, as noted in the case history of Sean. The incidence of prisoners who have experienced sexual abuse is higher than the national average. Many have not disclosed abuse until years later, which also manifests an intense anger, as seen in the case history of Dan. Incidents of loss and bereavement often cause anger that results in offending behaviour. This could be the death of a sibling, friend or, very often, a grandparent who had been offering emotional support and helping with parenting. The distress of bereavement is often a direct factor in young people turning to drugs or alcohol.

Conclusion Art therapy can reach the core of the problem and deal effectively with anger. Containment soothes and helps the pain or hurt, so the anger calms. Therapeutic boundaries give the client a sense of safety that their feelings will not run wild. The underdeveloped and traumatised area of the brain that is responsible for our emotional development can then be worked on and developed. Traumatic life events that are often dissociated and pushed into the subconscious will emerge gradually. It is then that the anger will settle and behaviour can alter. Then the process can percolate to the left hemisphere of the brain and be articulated in language, and then stored comfortably in the long-term memory. When this process is underway the cognitive processes of learning can also develop. This includes the ability to understand the triggers of anger – to recognise the feelings that create anger, and then to be able to articulate how we feel. Art therapy is a process which enables issues of loss that cause anger to be addressed. When the therapy has enabled emotional turmoil to be addressed, the cognitive processes of learning and language can develop. Emotional intelligence has to be addressed before intellectual intelligence can be accessed. Art therapy can offer young offenders an opportunity to recover from a variety of experiences of loss. This will remedy many aspects of anger and

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reduce or avoid further offending behaviour. Whilst inside prison they can develop coping strategies for many outside problems on release.

References BBC. (2005) News, December. Bowlby, J. (1988) A Secure Base. London: Routledge. Cairns, K. (2002) Attachment, Trauma and Resilience. London: British Association for Adoption and Fostering. Gerhardt, S. (2004) Why Love Matters. Hove: Brunner–Routledge. Goleman, D. (1996) Emotional Intelligence. London: Bloomsbury. Hollin, C. and Howells, K. (eds) (1996) Clinical Approaches to Working with Young Offenders. Chichester: John Wiley & Sons Ltd. Schore, A. (1994) Affect Regulation and the Origin of the Self. Hillsdale, NJ: Lawrence Erbaum. Zulueta, F. de (1993) From Violence to Pain. London: Whurr Publishers. Zulueta, F. de (1996) ‘Theories of aggression and violence.’ In C. Cordess and M. Cox (eds) Forensic Psychotherapy (Part I). London: Jessica Kingsley Publishers.

Further reading Liebmann, M. (1994) Art Therapy with Offenders. London: Jessica Kingsley Publishers. Paton, J. and Jenkins, R. (2002) Mental Health Primary Care in Prison. London: Royal Society of Medicine Press. Riley, S. (1999) Contemporary Art Therapy with Adolescents. London: Jessica Kingsley Publishers.

Chapter 6

Androcles and the Lion: Prolific Offenders on Probation Hannah Godfrey

Introduction This account draws on my experiences of working with both adolescent and adult prolific and priority offenders on probation in the community. This work has provided me with a wealth of material for this chapter, as I find myself working almost exclusively with the many guises and manifestations of anger.

The client group The clients in the setting where I spend most of my week are predominantly white males, usually between the ages of 18 and 45 years. The project that I am part of does not exclude other demographic groups, it is simply that, statistically, members of this group commit the most crime in the community and are therefore categorised as ‘prolific’ offenders and referred to our team. 1 The project focuses on ‘core’ crimes, such as robbery, burglary, theft and vehicle crime. Both multidisciplinary teams of which I am a part are designed to offer supervision and surveillance in the community to all prolific offenders, and to maintain this support throughout the stages of the criminal justice system. As part of our project, clients receive a package of drug treatment, housing and employment advice, restorative justice, education, mentoring, 1

‘Prolific and priority offenders’ refers to those individuals who commit a large number of crimes and cause the most damage to the community. The national strategy designed to target prolific offenders who commit common ‘core crimes’ such as burglary, was developed in 2004 by the government. (Lee and Wildgoose 2005.) 102

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art psychotherapy and so on. This is then placed within the framework of a commitment to public protection by the probation service and the police. The art psychotherapy service has been popular and well-used since its inception. I meet referred clients and explain the nature of the intervention. They may also refer themselves through their case worker. It is not compulsory to take part and only those who wish to begin therapy. If clients choose to take part, the session may be included as one of their statutory appointments, counting towards the hours they have to complete as instructed by the court. If they decline to participate, it does not affect their probation 2 licence or order. The art psychotherapy service was developed initially to help those clients who found it difficult to express themselves verbally, and who would benefit from an alternative form of self-expression, such as that offered by art-making.

‘Androcles and the Lion’ I hope to share some of the ways in which I work with anger. I have chosen to draw a parallel with the fable of ‘Androcles and the Lion’ (from Aesop’s Fables, translated by Gibbs (2002)). I intend to use this story to highlight the painful and debilitating nature of unresolved anger, like the thorn in the lion’s paw, and the care that needs to be taken when working with hurt and damaged individuals to remove the thorn and help resolve the pain. The fable, set in ancient Rome (Gibbs 2002, p.37), tells of a slave, Androcles, who escapes from his master. He is walking in a wood when he happens upon a wounded lion with a huge thorn in his paw. The lion begs Androcles to help him by removing the thorn that is causing him so much pain. The lion is very grateful and relieved. Years later, the slave is recaptured and is sentenced to death by being thrown to the lions, to punish him for his escape. However, the lion recognises Androcles as the man who had helped him and so spares his life. The emperor is so amazed by this that he allows both the lion and the slave their freedom.

2

There are several types of community order available for the court to impose, based on different requirements being completed by the offender. Essentially, this refers to a sentence imposed and monitored by the court, and served within the community. A licence refers to a residual part of a custodial sentence served within the community; if the client does not comply with the licence conditions or re-offends, he or she can be returned to prison. Both are supervised by the probation service.

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The lion with a painful thorn protruding from his paw, which hurts and restricts him, forcing him to ask for help, represents the anger that hurts and restricts a client. The client approaches me as a therapist and asks for help to diminish the pain that the thorn causes. Removing this painful thorn must be undertaken with delicacy and careful boundaries so as not to cause the client unnecessary further pain and anguish.

Anger and offending An article in Probation Journal by Mark Johnstone (2001) helped me greatly in thinking about anger and offending. Johnstone (2001) observed, through his work, how the social construction of masculinity makes it hard for young men to express their emotions: ‘The link between offending and gender refers to the part played in such behaviour by gender socialisation and role expectations (Worrall 1996). For men, there are personal, institutional and structural rewards for upholding dominant masculine constructs.’ (Johnstone 2001, p.11). He goes on to suggest methods for raising awareness of the social construction of masculinity during the supervision of offenders on probation. Johnstone (2001) discusses the gender split in offending – statistically, men commit by far the most crime overall. However, he feels that little attention is paid to the social construction of masculinity and how this is inherent in offending behaviour. For example, a young male offender who has limited access to legitimate forms of wealth and status, may steal or be violent in order to meet his gender role expectations to ‘provide’ and ‘protect’. As mentioned above, this type of gender socialisation leads to young males feeling unable or forbidden to express or address their sadness, anger and aggression appropriately. These difficulties, associated with the gender norms of being ‘strong’, ‘tough’ and ‘never being seen to cry’, may lead individuals to find an alternative outlet in destructive behaviour, aggression and violence, through acting out these thoughts and feelings rather than verbalising them. Offending and, more specifically, violent or damaging offending, may be viewed in some cases as a clumsy and disassociated method of expressing anger, frustration and despair. This is obviously extremely complex and differs for each individual client who begins to share their experiences in therapy.

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These aggressive and destructive offences seem to fit easily into a model of latent anger and aggression, bubbling up and spilling out from the subconscious to the conscious mind. A bottle of fizzy pop is a familiar and regular metaphor used by many clients I have seen in therapy wishing to illustrate and represent their angry emotions spilling out in a dangerous, explosive mess.

Acting out As I have described, offending could be viewed as a form of acting out. The individual engages in activities which could be a substitute for recalling and re-experiencing past events (Rycroft 1995, p.1). This is particularly poignant if a client cannot articulate and share these experiences. It comes both from a wish to understand the past and a wish to have their pain acknowledged and understood by others. In addition, as often happens in cases with multiple presenting issues, such as homelessness and substance misuse, clients may still be experiencing current as well as past traumas, and may be expressing their powerlessness by controlling external objects and expressing their anger through offending. Rycroft describes acting out as ‘replacement of thought by action’ (Rycroft 1995, pp.1–2). This is a perfect description for angry, destructive and violent offences being a replacement or sublimation of thoughts about past trauma, conflict and abuse. He describes the impulses as being ‘…too intense to be dischargeable in words’ (Rycroft 1995, p.2), thus, I feel, supporting art-making as an invaluable alternative form of self-expression.

Self-sabotage as a form of expressing anger A further inappropriate and passive expression of anger could be seen in a client’s non-compliance with a probation licence, which could result in a recall back to custody. A client who chooses not to attend appointments or attends, but behaves in an aggressive or threatening way, could find himself being returned to prison. This could be seen as a way of expressing angry feelings that cannot easily be articulated elsewhere. Clients may sabotage themselves and their own progress. This could be in an attempt to express the systemic anger at their position and circumstances, or a refusal to accept the consequences of their acting-out behaviour through offending. This has far-reaching and disappointing implications – not only for the clients themselves, but also for their families and the

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professionals who work with them. It can be very frustrating to watch as a client rejects the opportunities and support they are offered. It is important that the client wants to engage in therapy. They must be allowed to ask for the thorn of anger to be removed. They must also be prepared not to attack the person whom they allow to help. Winnicott says that the positive changes after an implied attack on the analyst do not depend on interpretive work, but on the ability of the analyst to survive. For example, if the analyst is aware his patient is carrying a gun, he cannot sustain such attacks (Winnicott 1969, p.108 cited in Schaverien 1999, p.36). With this client group, especially in sessions focused on anger, survival of physical as well as metaphorical attack has to be considered. Before working with a new case, I have access to the client’s probation file and a risk assessment completed by their probation officer, including information such as any history of violence against staff, physical attacks on women in particular and so on.

The paradox of anger in therapy There is a paradox with many clients who say they need help containing their temper or angry feelings. They often present a selection of barriers to beginning this work. Clients warn me that they cannot actually discuss what makes them feel angry or the reasons why they might feel this way, as they are liable to become violent and angry – thus effectively placing an embargo on all areas related to anger and limiting how we can address it. I liken this to Androcles being asked to take the thorn out without touching the lion’s paw or a dentist being asked to treat a toothache without looking inside a patient’s mouth or touching their teeth. I have to assess carefully the client’s willingness to take responsibility for their anger and their actions. Often, in assessment, individuals state that their anger appears to come from nowhere, has no particular warning signs or catalysts, and could erupt at any time with no hope of controlling or containing it. They say they just ‘see red’ and fly into a rage, suggesting that they have no responsibility for their anger, and cannot be reproached for this as it is outside of their control. I try to explore this with clients and start to deconstruct what it really means to them, as it has implications for safety for myself as the therapist, and also the wider community in terms of public protection and further offending.

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Case study: anger in assessment 3

Steven was referred to me by his case manager, who said that Steven had significant issues with anger which were reflected within his offending. The team questioned whether or not I should see this client alone, owing to risk – he was considered difficult and had presented problems for staff in the past. However, I did not feel that I could build the necessary therapeutic relationship with Steven if I was accompanied in sessions. As a compromise, we agreed as a team that I would see him alone, but that other staff would be ‘on hand’ if there were any problems, and would check on us through the glass in the door at intervals during the session. This build-up to the assessment engendered in me quite a defensive and hyper-vigilant state, obviously affecting my expectations of meeting Steven. Steven did indeed have a formidable physical presence. He seemed to work hard at maintaining this as it appeared extremely effective at keeping people at a distance. He was dismissive and negative about me and the session. He was defensive and questioned my qualifications, describing me as ‘some sort of quack head doctor’. However, he begrudgingly stated that he needed help to work on his aggression, as he felt it was causing him to offend. I asked Steven to tell me about his anger. He explained that we could not discuss it at all as he would become angry. He warned me, apparently genuinely, that he would not be able to guarantee my safety within the session. He could not promise that he would not attack me and explained that he would consider using a weapon if I touched on a particularly sore spot as we talked. However, he was unable to tell me where the sore spots were. It was clearly unsafe to work with Steven at this point, so I had to tell him that I could not work with him. I felt that he was trying to scare me to keep me away, whilst also feeling vindicated that he had asked for help and then not received it, placing the blame firmly with me. This reinforced his disappointment with the system’s failure to help him and his belief that he was, ultimately, impossible to help. Steven remained angry at what he considered to be me refusing to help him. He approached the assessment as if he had been given a doctor’s note excusing him from addressing his issues. I felt he was effectively stating: ‘I am angry and need help with this. However, I must be excused from all 3

All names and identifying features have been changed to protect the anonymity of the clients.

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mentions of anger and its catalysts as I will become angry, but will bear no responsibility for this as I have identified myself as an angry person.’ I, in turn, felt angry at having been threatened, though more significantly, I felt deskilled and disappointed, with a great sense of failure at not having found a way to reach Steven. This demonstrates the powerful transference, from one short meeting. I actually felt guilty for being unable to help him, rather than feeling protective of my own safety. In addition, I felt the expectations of the team who hoped that art psychotherapy would prove the panacea for this extremely difficult, prickly and prolific offender.

The function of aggression I considered for some time why Steven could not accept help. I began to consider what he would be giving up if he chose to address his angry and aggressive persona. It would be hugely significant for a man to change, who had lived his whole life identifying himself, achieving goals and acquiring status, money and respect through anger, aggression and violence. He would have to abandon his value system, his livelihood through his offending, his friends and, possibly, family. He had never worked in legitimate employment. Having a fearful and notorious reputation is a functional and desirable device in some circumstances. The individual may enjoy safety and security, control and financial gain through offences related to maintaining this reputation. Steven may have established that he had issues with his anger, but he was not yet willing to give up the lifestyle that his anger and aggressive behaviour had established. Unfortunately, on this occasion, the lion was neither willing nor able to relinquish the thorn to Androcles. The metaphor is open to a little interpretation here, as in the fable Androcles removes the thorn from the lion’s paw altogether. However, I am not advocating the removal of all anger. Anger has a role and a function and (where appropriate) allows people to defend themselves from attack. My goal is not to leave a client vulnerable and undefended. Aggression and violence are a realistic part of the life of a young male living in an economically disadvantaged, difficult and challenging urban setting, or spending time in prison. The aim of the therapy is not to remove anger. Rather, it is to address unresolved past aggression and acting-out behaviour, to offer a safe and alternative way of experiencing and processing the strength of these feelings, and to use art-making as the vehicle for some of this material.

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Case study: expressing anger passively In the previous case study, Steven was very aware of his own anger. He used it to his advantage and understood its power, so much so that he found this power and control difficult to relinquish. My next example is of a client who experienced anger very differently. His experiences represent a familiar pattern of many clients who split off and deny their angry feelings for fear that their power might annihilate them. Jason was 21 and presented as slightly shy, anxious and vulnerable. It became clear at the start of the therapy that Jason found the intimacy, warmth and containment of the therapy overwhelming. He found it hard to make eye contact and often appeared so fidgety and uncomfortable that he had to leave the session altogether. Gradually, over a period of weeks, he began to be able to stay for longer and make better use of the sessions. Both Jason’s parents were also known prolific offenders. He was an only child and the whole family, including the extended family, was involved with Class A drug use and offending, involving Jason in this from childhood. Jason was living with his parents on his release from prison. Jason had already served several sentences in young offender institutions. He had a history of truancy and fragmented education, and was eventually excluded from full-time education. The family also had a history of social services intervention. On reading his case notes and previous offences, I had prepared myself for a hard, well-defended and streetwise individual, who was well-versed with the system and knew how to manipulate it to get what he wanted. However, what I found was completely incongruent with the image I had allowed myself to imagine. Jason’s previous convictions were extensive and serious. However, he did not fit easily into this stereotype. He was friendly, polite, funny and compliant. He seemed, dare I say it, ‘nice’. This impression felt authentic and was shared with the whole team – everyone enjoyed working with Jason. Despite his amenable presentation, Jason appeared to have a great deal to be angry about, and seemed to have been badly let down as a child and adolescent. Yet he did not appear to feel, acknowledge or express any angry or aggressive emotions. He seemed to rise above them and deny their existence. If he had not been involved in a high-intensity project for prolific offenders it might have been easy to assume that he was a happy and well-adjusted individual, yet his drug use and offending pattern betrayed and exposed the painful thorn in his paw.

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Jason made excellent use of the therapy and completed 12 sessions initially. During these I felt that he began tentatively to acknowledge and explore some of the anger he worked so diligently to split off and deny. Jason was a talented and creative artist and really enjoyed using the materials. He was suspicious at the beginning of the therapy about what the information gathered from the sessions would be used for. He also often commented on the smallness of the room where we worked, and the intensity and discomfort of sharing this small space with me. Gradually, Jason’s anxiety started to subside and he began to worry less and use the art materials more. I would like to share two of Jason’s most significant images from the therapy: first, a clay sculpture of two elephants and their keeper; and, second, a decorated mask. I will also discuss the value of mask-making in helping people to express anger appropriately and safely in therapy.

Clay elephants Jason made one large elephant and one small one (Figure 6.1), which he connected one behind the other by their tail and trunk. They were beautifully crafted and carefully finished. He said he wanted to make the elephants as he knew something of their parenting skills and thought that they really looked after their children. He explained that this started with a gestation period of 22 months. He expressed this with amazement and a little envy at what he considered to be the comfort, security and love afforded to the baby elephant by its mother. The elephants took Jason the whole session to complete and he spoke while he smoothed the clay. Just before the end of the session, Jason decided to make a rough figure of a man to sit astride the female elephant. Both the elephants had been created lovingly, conversely the man was made quite roughly and his limbs joined quickly, clumsily and without much care. Inevitably, over the duration of a week, the elephants dried triumphantly, but the man fell apart. His limbs where dangling precariously by the threads of nylon within the clay and he was fragile and weak. I felt that the similarities with his own family dynamics were striking. I could not help but notice the comparison with Jason’s experience of his own father, who was seldom available to him or to be relied upon. He was chaotic, aggressive and often absent. In addition, he had been left physically diminished by many years of heroin use. The mother elephant represented an aspirational image of his mother and their relationship as he would have liked it to be.

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Figure 6.1 Jason: Two clay elephants and their keeper.

At the beginning of the next session, Jason initially wished to dispose of the damaged clay man. Perhaps this reflected an angry wish to annihilate and dispose of his ‘useless and damaged’ father, and to have his mother free to care for him completely. Jason later retrieved the man from the bin; he mended him and then placed him again on the back of the mother elephant. I felt this demonstrated the conflict for Jason: he was angry at his father for the past, yet he also hoped to mend him and to benefit from his guidance and create a strong family unit. Jason painted the elephants in ceremonial colours after saying that he had a seen a documentary about elephants in India. He was proud of what he had produced when he had finished. We were also able to discuss the ideal of parenting that the image represented, and he could see that he had depicted his own ideal family dynamics through the image.

The use of masks to express anger As part of the materials available within the art room, I provide a choice of blank plastic masks to decorate. They have proved extremely useful tools and a popular choice. This is especially true for those wishing to express angry

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feelings. The masks provide a degree of separateness and distance that offers safety and makes the expression of painful feelings possible. Many clients independently produce strikingly similar designs, and choose the same colours and materials when they decorate these masks. I have witnessed many similar combinations of red and black forming dynamic, frightening and demonic creations made by different clients at different times. This similarity seems to represent an archetypal connection between the images. Schaverien (1999, p.21) describes the apparent repetition of images and symbols in separate therapies. She identifies, as I have, the synchronicity often seen through images made independently by people who have experienced similar life events. She describes the archetype as having universal dimensions, but also including individual elements. Therefore there may be occasions when individuals with similar cultural experiences, personal circumstances and states of mind, produce similar images. The mask affords a client an opportunity to ‘try their anger on’ safely. They can literally pose and posture with the mask, experimenting with the force and form of their anger outside themselves. They can practise integrating the angry feelings and emotions by placing the mask on their face and then removing it again. By showing me, the observer, they can show the true face of their anger. In doing this they can practise expressing their angry feelings to an observer without annihilating them. They can have those feelings accepted and recognised, and still have the observer ‘survive the attack’ (Winnicott 1969, p.108 cited in Schaverien 1999, p.36). The masks also offer a physical way of demonstrating to a client the idea of splitting off aspects of the self if they find this concept too abstract to understand verbally. It allows a client to rehearse and experience the wish to annihilate the source of the anger and to face the significance of this ‘unacceptable wish’ (Schaverien 1999, p.36). This also facilitates the important distinction between fantasy and reality. Through mask-making the client can physically practise integrating split-off material and this can lead to useful dialogue. This can help prepare a client to accept their split-off elements back into their true self in a more acceptable and digestible form. The client can allow the mask to represent, express and contain many angry feelings and emotions. They can then reflect on these from a safe distance rather than being consumed by them from within themselves.

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Many of the masks produced have been used to contain unmanageable, negative, split-off material. However, some masks have been used to contain positive split-off elements. These masks have often incorporated many of the fine and rich materials within the room, such as metallic paint and glitter. This could represent a wish to keep the good split-off aspects safe and preserved. The client may need to practise integrating this positive split-off material into their understanding of themselves, as much as the negative.

Jason’s mask Jason chose to decorate a mask using red (for the face) and black oil pastels, with yellow blood-stained horns (Figure 6.2). The pastel adhered easily onto the shiny plastic mask, giving it a rich painted effect. The mask was demonic and fearful, yet felt as if it contained a plethora of complex emotions, including a slightly melancholy, sad quality. The black square at the bottom showed a protruding tongue, made from masking tape and coloured in oil pastel, then attached inside the mask. The horns were made of twisted tissue paper and looked as if they would be crushed in any altercation or conflict.

Figure 6.2 Jason: Red and black mask.

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This made the mask confusing to view and embodied Jason’s mixed and confused feelings about his anger. The mask had a hard and aggressive quality but also looked as if it might fail to protect the wearer. It expressed both hard and soft, angry and passive qualities. Jason was not ready at this point to put into words what this image meant to convey, but was better able to do so in hindsight. On his return to therapy he explained that he now felt more in touch with, and able to acknowledge, his own anger than before; he felt that the mask had focused and carried some of this for him. Jason initially completed 12 sessions of therapy. He returned to the project again after he had completed a short spell in prison for an offence of handling stolen goods. By definition all my clients are ‘prolific’ or repeat offenders, so I do not consider it a failure when a client offends during or after therapy, but rather an entrenched pattern of behaviour that takes time to address. Jason explained that he had had time to reflect on his therapy while he was in prison and that he had begun to recognise his own anger. His presentation was quite different when I saw him again. He seemed more robust and less vulnerable and anxious. He explained that he had begun to feel extremely angry but did not understand why. He was surprised at the strength of these feelings and understood that they had always been there, but that he had been denying them and splitting them off. He was relieved to finally feel them and discuss their meaning. We were able to reflect back on the images Jason had made in therapy, and he was able to acknowledge his angry feelings and to understand their source. He realised that his unhappy, unstable and unsatisfying relationship with his parents as a child played a role in his current anger. He began to work on practical ways he could express and address this dissatisfaction, and make changes to establish a more fulfilling relationship with his parents in the present. Jason chose to leave the images with me to carry the heavy weight of the material for him. Clients may choose to leave images or masks with me to add a further dimension of disposal or they may simply have no need for the image as they have used it successfully to reintegrate the split-off material. Jason was keen for me to use the images he had made to educate others about art psychotherapy and how it can be applied. In her writing about scapegoat transference, Schaverien (1999) describes the positive benefit and need for split-off elements to find a vessel within the image. She cites the work of Perera (1986, cited in Schaverien 1999, p.33), who comments on the role of society within the myth of

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scapegoating. I feel there is a parallel between reintegrating the split-off elements of the self and the reintegration of ex-offenders back into society. The art-making within the session can offer a client a way to acknowledge the shadow aspects of the self, such as their anger and rage, and also their frustrations with the dominant power system which judges them and their behaviour.

Conclusion In writing this chapter I do not mean to suggest that by addressing anger and ‘removing the thorn’, all clients will become moral, law-abiding citizens and we will have resolved their recidivism outright. Anger lies among many varied and complex catalysts for offending, such as drug addiction for example, which I have not chosen to address here. I hope I have demonstrated the link between unresolved angry feelings and ‘acting out’ through offending behaviour, and non-compliance within the setting in which I practise. This can be successfully addressed through using art psychotherapy for those that choose it, as I have shown through the case examples. I am often astounded at the level of insight and self-reflection demonstrated by many clients who attend therapy, and their realisation that unresolved anger and referred aggression from past experiences have been catalysts in their offending. Of those clients who seek help, not all are ready to accept the implications of having their thorns removed and their anger addressed. However, for those clients willing and able to address their angry feelings through therapy, I hope to help them to understand themselves better, and through understanding the source of their offending behaviour, I hope to offer them the opportunity and motivation to change.

References Gibbs, L. (2002) Aesop’s Fables. Oxford: Oxford University Press. Johnstone, M. (2001) ‘Men, masculinity and offending: developing gendered practice in the probation service.’ Probation Journal 48, 10–16. Lee, C. and Wildgoose, K. (2005) Prolific and Other Priority Offenders (PPOS): Summary of Actions and Monitoring Arrangements. National probation service circular 79/2005. London: National Probation Directorate. Available at www.probation.homeoffice.gov.uk/files/pdf/ pc79%202005.pdf, accessed on 8 April 2008. Perera, S. B. (1986) The Scapegoat Complex. Toronto: Inner City. Rycroft, C. (1995) A Critical Dictionary of Psychoanalysis. London: Penguin.

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Schaverien, J. (1992) The Revealing Image. London: Routledge. (Republished 1999, London: Jessica Kingsley Publishers.) Winnicott, D.W. (1969) ‘The use of an object and relating through identifications.’ International Journal of Psychoanalysis 50. Reprinted in Winnicott, D.W. (1971) Playing and Reality. Harmondsworth: Penguin. Worrall, A. (1996) ‘Gender, criminal justice and probation’. In G. McIvor (ed.) Working with Offenders. London: Jessica Kingsley Publishers.

Chapter 7

What Anger? Working with Acting-out Behaviour in a Secure Setting Kate Rothwell

Introduction Most people are familiar with the conflicts inherent in everyday life where individuals vie for attention, territory and status. Anger is never far away in a host of ordinary everyday emotions. Usually, no one dies when expressing anger but rare is the person who does not occasionally feel like killing someone. The point I am making is that, rather than being an emotion that has to be hidden, the expression of anger makes up some of the very fabric on which life is built – unlike for the people I work with, who have survived by burying their anger. Unable to contain their feelings, they have come to act aggressively on their fury, hatred, fear, paranoia and pain, to catastrophic effect and fatal consequence. In this chapter I focus on my work in forensic settings with offender patients who have histories of mental illness, personality disorder or learning disabilities. The crimes they have committed are violent, impulsive and destructive, but rarely calculated or organised, although they may be preceded, and are often inflamed, by a sense of outrage, misunderstanding and fear. For instance, one inmate told me she stabbed her doctor in the hand because he would not prescribe her the medication she thought would cure her – she was angry and hurt at what she perceived to be his lack of care and concern. Patients speak of their loss of control, saying, ‘I couldn’t stop myself, I didn’t know what I was doing’; details are forgotten, but the memory of the

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trauma that led to the offence stays somewhere in the body, causing them to ‘act out’ not ‘think out’ (Teasdale 1995). Judging by the degree of dangerous and aggressive acting-out reported by staff of the patients referred to me, I fully anticipated this would be replicated in the art therapy sessions, and adapted the materials and space accordingly. What happened, or did not happen, surprised me. The patients I saw were not ‘out of control’; in fact, they used the space and materials appropriately. Then, through the process, an attack on the therapy and space did emerge but disguised in the image, not dissimilar from a symbolic use of a weapon. Something different was happening and this interested me because many of the patients I work with have most commonly used a weapon, such as a knife or hammer, in their crimes. However, the patients in therapy were controlling how they used the materials, the content of the session, their behaviour and emotional responses. Their images conveyed coded representations of violence and aggression causing me to work instinctively with caution and wait to be invited to respond. To show this I shall discuss Heather, who used art therapy to visualise her murderous fantasies in an attempt to frighten the therapist, whilst simultaneously threatening to take a hostage. Her anger was acted out to help her feel safe when she felt vulnerable. She used art therapy as a coping device to moderate and develop an understanding of her feelings, prior to her release. I will then discuss Philip who was imprisoned for grievous bodily harm and carried anger from childhood. What I want to convey is how acting-out behaviour is sometimes used within a forensic setting when anger gets buried, but that non-verbal processes in art-making may provide an opportunity for material to surface through the work, held within the therapeutic relationship and space. This may be a necessary ‘intermediate’ developmental stage serving as a safe space in itself for the expression of feelings yet to be realised.

Anger in a secure setting: some theoretical perspectives Re-experiencing, re-working and re-thinking anger in a secure environment is exceptionally difficult for anyone attempting to work therapeutically. People in prison gain some sense of security by expressing their anger externally towards authority figures, and feel justified in doing so, but prison environments do not lend themselves to reflective processing and any attempt to create a space to think and hold difficult feelings is met with enormous resistance.

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This may in part be explained in the writing of Williams-Saunders, a psychotherapist in forensic psychiatry, who describes how, for prisoners, ‘Concrete objects have often stood in for a symbolic representation of a good-enough internalised parental object, so that concrete holding must be sought out’ (Williams-Saunders 2001, p.18). This means that concrete needs tend to be responded to with concrete nurturing, and emotions such as anger, imbued in dangerous acting-out behaviour, are ‘managed’ through medication or controlled observation rather than thought about. Prisons and secure settings provoke acting-out behaviour which tests the security and holding capacity of the environment, as in Winnicott’s (1971) theory of delinquency as hope, whereby the anti-social behaviour may be likened to an SOS signal. Freud (1964) defined ‘acting out’ as an act, or series of acts, that are a substitute for remembering. Early attachment work (Bowlby 1988) shows us that the mother needs to accept and receive her child’s anger to provide emotional boundaries and containment which help her child to make sense of incomprehensible feelings. If the child’s anger is met with the mother’s anger, it can become a terrifyingly uncontained, overwhelming and catastrophic experience. Anger then becomes dangerously buried and denied, for fear it will destroy and annihilate loved ones and the self, or enacted through humiliated fury and murderous rage. For offender patients self-destructive acting-out behaviour can be very immediate, temporary and reassuring as a defence, but it will not provide anything more lasting than superficial relief from emotional pain. With anger there is no thinking – it is the antithesis of processing on an emotional level. Imprisonment is the ultimate container for the offender’s aggression. Angry feelings become more deeply buried in the unconscious and too risky to expose, as they can generate high levels of anxiety and insecurities in staff, who fear loss of control. Anger is possibly the least tolerated emotion in the system. For this reason the patients I work with are extremely anxious about their vulnerabilities being exposed, uncertain of what they can cope with seeing in themselves, and whether others can tolerate their rawest emotions. Containment in any therapeutic setting is fundamental. With art therapy in a forensic setting the offender patients can develop a symbolic container inside themselves through the medium of art-making. This may be the first experience of destructive and traumatic impulses being held rather than acted on. An enactment may still take place but contained in the image,

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where feelings can surface in visual form. I see this as a first stage of development before play and risk-taking in the relationship is possible. The violent patient may need an intermediate space, where feelings of trust and safety in the therapy can be built, making it bearable to reconnect through the process with thoughts and feelings linked to the crime. Levens (1989, p.144) states this clearly: ‘The client may use art to test out his dangerous thoughts and ungratified wishes in a safer way than directly in relation to the therapist.’ I also rely on containment and boundaries to keep me safe whilst working with potentially overwhelming material, evident in my caution and the importance I place on processing countertransferential material in clinical supervision. This creates a reflective space that helps me find meaning in the projections I am holding and to piece together my own thinking. I will look at the process of art-making as a container for anger yet to be realised, through examples from my work: one from a female remand prison and the second in a secure mental health setting. But, first, I will talk about a particular incident that happened in the prison.

Female remand prison ‘You’re the bleedin’ art therapist’ This prison wing was dedicated to detoxification and post-rehabilitation treatment for women undergoing drug rehabilitation in the prison. The women on the unit committed themselves to a three-week drug rehabilitation programme and had the choice to attend a weekly open, directive art therapy group, which I ran in the unit dining room, co-facilitated by a trainee art therapist. With a fast-changing population, it was not possible to assess anyone beforehand, so I simply informed the women of the group and invited them to participate. I tried to create a space that felt cared-for and valued to help the women engage quickly by beginning each week with introductions. I tried to remember their first names to address them personally as individuals, in contrast with the prison staff who used inmates’ last names or numbers. I also covered the tables in patterned vinyl to combat the institutional atmosphere and brought along a large folder to contain all the images made in the group. Many women brought disturbing material, but one particular experience had a profound impact on my thinking about the importance of containment to hold anger and distressing feelings.

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On this occasion a young African-Caribbean woman entered the room, already occupied by two group members, the trainee and myself, all four of us of white racial origin. Barging up close to me, she demanded, ‘What does black mean?’ She asked again and again, ever more persistently. Nervously, I replied: ‘You’re thinking about something and have a question you want answered, but perhaps we can wait until the group begins to think about this together?’ She became very irritated and repeated the same question, adding, ‘You’re the bleedin’ art therapist, you should know what black means!’ I felt anxious and bullied by her demands. Unsure what to do for the best I found myself asking aloud if we could start again. This is what I said: ‘I think black can mean different things to different people depending on who they are. People’s background, racial origin, their likes and dislikes, where they are from. Black can be a colour – one that symbolises beauty or badness perhaps? It can hold different meanings, there is no one meaning. It can mean something different to all of us at different times. What does it mean to you?’ The young woman went on to tell the group a very distressing story of how her two young children were taken away from her into care by social services, and how these people had interpreted her children’s use of the colour black in their drawings as a sign of their depression. The woman took this as a reinforcement of her not being a good mother, detected or even betrayed through the drawings and used, she believed, as further justification to remove her children from her care. It seemed that an invitation to join the art therapy group had opened up very raw emotional wounds for her and that she had brought her pain and anger to a place where she hoped she might find some answers – or retaliation perhaps against ‘the professionals’? After this exchange, the woman made an image that she chose to share with the trainee, who also had a distinct cultural identity, noticeable through her French accent. It seemed that this different sort of experience in the group had enabled a very damaging, unthinking and racially misunderstood experience to be reworked or revisited. By the end of the art therapy session, we were able to understand this woman’s experience in a more meaningful way. As a hot-house for acting-out behaviour, a secure setting increases the potential for the therapist to be drawn into dangerous scenarios, but the process of art-making in this case allowed a thinking space to grow and hold the anger that was brought into the group.

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‘More sides than a fifty pence piece’ One of the most dangerous and disturbing patients I worked with in the prison was Heather, who was referred for individual art therapy from the hospital unit where vulnerable women are held if in need of medical attention and nursing. Coming to the end of a four-year sentence for drug-related offences, Heather had not received any form of psychological treatment before, despite her history of self-harming, including self-strangulation. A succession of psychiatric reports on Heather listed various ‘personality disorder’ diagnoses, fuelling the notion that she was untreatable. Well aware of this, she described herself as having ‘more sides than a fifty pence piece’. She also had a long list of previous offences, including a finding of physical abuse towards children. Heather described her childhood as unhappy and isolated, both at school and at home, with an older brother who introduced her to drugs, an anti-social father and a mother whom she described as cold and aloof. Heather said that she attributed most of her mental health problems to being raped at the age of 13 by a man unknown to her. Heather’s history of severe self-harming and threats to take a hostage or kill someone, made the work challenging and precarious, though I sensed her threats were about keeping herself and others safe, like a comforter to soothe her anxiety. On these occasions it was reassuring to me that the nurses took a very concrete stance (despite my reservations expressed earlier in the chapter), as it prevented Heather acting on these fantasies and risking my safety. ASSESSMENT

I offered Heather an art therapy assessment session and we chose to meet in the glass-fronted dining room opposite her cell where officers could see us, more for Heather’s safety than mine, she said, though we were both anxious. Heather described the images she first brought to the session as doodles. Initially, she would not draw in the session, preferring to use the time to discuss her pictures (done in her cell) in an incongruously friendly manner, to describe herself, her experiences and her life in prison. Heather presented as intelligent, self-assured, motivated and insightful – characteristics observed by other team members. I was scared of Heather, as the disturbing and violent content of her images belied the person she chose to portray to others, for example the

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depiction of the knife cutting the wrist in Figure 7.1. I was seeing a different side to her and felt she was sending me a warning to keep my distance.

Figure 7.1 Heather: Doodle (detail). TREATMENT

Heather agreed to attend further individual sessions over a three-month period, during which time I gained a sense of the degree of damage, intensity of anxiety and sheer rage in Heather, in particular in her doodle, which read ‘no hope, no dope, no ale, no bail, just jail’ (Figure 7.1). During subsequent sessions Heather developed enough trust in the containment of the process to make images in my presence; however, there were days when she felt unable to attend, and times during sessions when I needed to check whether she felt able to continue. In one very significant session, Heather depicted a disturbing dream or fantasy of a young child lying dead under a pile of leaves. I felt my reactions were being tested in her attempt to mask her anxieties in the session, and this

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left me feeling fearful. I suggested to her that if there was ‘no hope’ of containing her anger and violence, how could we think realistically about her future in prison? This led to a discussion with Heather concerning her anxieties about being released within the next year. She said if she felt at risk herself – whether real or imagined – it would be worth her while, in her mind, to take dangerous and drastic action to protect herself. From this point on, Heather was able to emphasise her need to feel safe and contained, and for her potential for violence to be taken seriously. She felt a sense of relief in exposing her dangerousness and fears through her images and the art therapy process. Increasingly Heather’s presentation was of a terrified little girl rather than the monster she was felt to be. Her anger, though heavily disguised, was always apparent to me in the artwork as I came to recognise her symbolic language. She told me that she regularly tied ligatures around her neck, and kept lengths of material on her person to reassure herself when stressed, and she sometimes exposed the self-inflicted injuries on her arms. This ensured that staff remained alerted to her needs and was perhaps another safety measure she employed to contain herself, lest we forgot! The approach I have described is one that concentrates on facilitation, holding, containment and consistency, rather than interpretation, to create a safe space for thinking and feeling. Heather’s resistance and fear of feeling led to her acting-out in extreme ways through violent and impulsive self-destructive behaviour, each an expression of dangerously repressed anger, pain and anxiety that chastised her mentally and physically. Levens (1989, p.146), discussing Freud’s views on resistance, states ‘Recovery is treated by the ego as a new danger. The art therapist should, therefore, understand the nature of resistance in all its guises, and be able to credit it with the respect it demands.’ Certainly, one task of an art therapy assessment in a secure setting is to weigh up how far patients find thinking dangerous, whether they feel safe enough in their own minds to tolerate angry thoughts rather than act on them. Reconnecting with anger is like a double-edged sword for offender patients, as recognising internalised conflict buried in the unconscious may increase the risk of suicidal, depressive and aggressive behaviour if they feel exposed, humiliated, ashamed or disillusioned. The concrete nature of art materials and art-making naturally enables patients to remain in control of their own process. My task at the image-making stage is to hold the thinking

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space and to contain, not voicing any thoughts until the patient is ready to integrate more of the therapeutic relationship into their internal world. The next case example is taken from my work in a medium-secure setting and explores the role of art as intermediate containers for angry and aggressive feelings.

Mental health medium-secure unit ‘I go so far then ruin it’ The medium-secure unit is run like a mental health hospital, with dedicated multidisciplinary teams, medical models, cognitive behavioural therapy, psychological testing, risk assessments and a range of therapeutic and educational services. Much of the clinical work is focused on compulsion and psychopathology, with patients sectioned and detained through the courts in response to their offences and the risks they present. The hospital has an established arts therapies department, which provides (through a process of referral and assessment) a treatment approach chosen by patients who feel more able to express themselves authentically through non-verbal forms. I work in a well-resourced dedicated art therapy room, acknowledged by the patients as a different kind of space from the rest of the hospital and vital for any serious in-depth treatment. A characteristic shared by many patients referred to art therapy is a history of acting-out behaviour on the wards, yet a reluctance during art therapy sessions to make connections with real emotion in a process that can require a long-term commitment, as this requires working through the 1 anxieties inherent in acting-out behaviour, to find a safer form of expression through art-making. I will now discuss a patient referred to art therapy from the men’s mental illness team in the medium-secure unit.

Philip Philip, a shaven-headed, 33-year-old, white, single man with a working class background, was initially imprisoned for committing a non-fatal stabbing offence, but was transferred to a low-secure mental health setting owing to staff concerns for his mental health. He was transferred from low to medium 1

It is important to note that all staff carry panic alarms or radios to call for help if needed. In some cases escorts are used to accompany patients during the art therapy session.

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security for causing serious damage to property and attacking patients and a nurse. Diagnosed with paranoid schizophrenia, compounded by drug use and complicated by personality disorders, Philip was volatile and aggressive towards fellow patients and racially abusive to black and minority ethnic staff. ASSESSMENT

Philip was referred to art therapy with the aim of improving his insight into his mental health problems. I assessed Philip over four weeks and continued working with him for a further 15 months. To begin with, he told me he was a normal guy who did not need therapy and was complying with treatment as a strategy to be released earlier, but he liked drawing and wanted to improve his art skills. His first image (Figure 7.2) was a self-portrait as a devil.

Figure 7.2 Philip: Self-portrait as a devil.

In this session, Philip began working with oil pastels on an A4 sheet of white paper and liked the effect ‘like sky’, then put flames in the foreground. Philip thought it did not look realistic enough. He told me his image was hell and wondered what hell looked like as he had stabbed a man, nearly killing him, and thought he might be going to hell. Philip added a devil’s face. He said he

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used to ‘kick off ’ when things annoyed him, like people being stupid, or if he felt menaced or bullied, but now he was feeling more tolerant. However, there was little indication of this tolerance on the ward as he continued to be racially abusive and physically aggressive. Philip told me about his life, his impoverished childhood, his stepfather’s suicide when he was eight years old, and how his natural father had abandoned his mother when Philip was born. He stated that he did not like men but would never hurt women. I listened, feeling uncertain whether I was safe or whether he could work constructively with his aggressive impulses. Philip brought his feelings to the work in the form of images. His next image was of a tank moving through war-torn, smoke-choked ruins and flaming trees (Figure 7.3). He was simultaneously self-critical and pleased with the smudgy effect he had created, saying ‘I go so far, then ruin it, but it’s OK’. He used chalk pastels, as he liked the effects he could achieve by rubbing with his fingers and softening the marks. I was very conscious of the tank gun pointing towards me.

Figure 7.3 Philip: Tank.

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TREATMENT

When he was feeling well, Philip used the sessions to draw, then chat about himself in a matter-of-fact way, but his attendance was erratic, he refused medication and was violent to fellow patients, also making racist threats. Yet, in therapy, he was exploring our relationship and who I was; Philip seemed confused about my identity and I wondered if this reflected something of his own uncertainties about who he was. Philip told me that he was ‘justifiably angry’ and frustrated towards his doctor for what he saw as the ‘unfair injustice of the system keeping him locked up’ and depicted these feelings in an image (Figure 7.4).

Figure 7.4 Philip: ‘Expressing myself ’.

This picture shows a red and black background with black and red dots, black zig-zag lines and a tree shape on each side of the page. It was the first of a series of very dark, sombre images conveying something of a menacing and sinister feeling. All Philip could say about it was that he was expressing his emotions, but denied feeling anger, least of all towards me, as I was ‘just an art therapist’. Wondering whether Philip could take anything from the work without attacking it, I reflected with him on the gaps in his attendance and the possibility of still coming to art therapy when he felt less well, as we could only

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think and work together in session. He said he regularly did not feel like coming to therapy but did so, and stated he was only participating in order to get out more quickly, but also so that he did not keep making mistakes. Having made violent and near-fatal mistakes in the past seemed to resonate in Philip’s image-making; he would begin working with light, bright colours – then add black which obliterated any definition underneath, causing him to feel he had spoilt his picture. Philip’s responses felt genuine but still the conflict remained outside the sessions until, after a long break, a patient he knew that I had worked with committed suicide. The following session Philip painted with short, flowing lines of bold colour in an abstract manner (Figure 7.5) and commented ‘I’m expressing myself emotionally’, then, realising what he had painted, described it victoriously as a ‘swastika’.

Figure 7.5 Philip: Swastika.

Philip told me how he felt towards ‘Blacks’, and said he was a neo-Nazi supporter, then entered into a lengthy rant about his violent racist activities before contradicting himself, saying he was a pacifist who did not harm

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anyone. He went on to tell me that his mum was strong, but the family lived in poverty with a second-hand carpet which did not reach the damp mouldy walls and was covered in dog faeces. He described having no money, eating ‘stodge’, growing up in a culture surrounded by prostitutes and drug-pushers, and how he felt proud of his grandfather who had fought for his country in the war. His powerful communication left me feeling sick after sitting through the full force of his gleeful and sadistic assault, which put me in touch with his most unpalatable and disturbing emotions. The session ended with my impression that Philip and I were the veterans of our own traumatic battle in the work and also in life. SUBSEQUENT SESSIONS

After this onslaught, Philip settled into exploring different aspects of himself over the next few weeks. I was left thinking about his anger in the session and my vulnerability following the news of the other patient’s suicide. Was he punishing me for putting him in touch with his feelings of loss and rejection replicated in my not being able to keep the patient alive, and not being ‘strong enough’ to ‘save’ him? I did not assume anything but was aware that I had experienced something of what it was like to be Philip and felt this shift was significant enough without interpretation. Anger was in the arena, and more importantly, in the images. Over the weeks Philip moved from working with dark, sombre colours into using brighter, clearer ones. He talked about mess in his pictures and was less attacking towards the therapy, shown by his increased willingness to attend sessions. During the latter stages of therapy Philip had another humiliating and painful experience with the potential to enrage him. Initially declining his session he did, after all, attend and resorted again to racially abusive language. Despite this, we were both able to think more clearly about his feelings, and he went on to talk about feeling angry as a child but not knowing why. Relating this to his offence, Philip said he had always lost control when he became intensely angry, and described how he ‘blacked out’, causing him to lose his memory. Significantly, he was now remembering and beginning to think about his anger. ENDING TREATMENT

Reviewing Philip’s work together, we discussed how he still felt angry but seemed to be coping more successfully. Philip said he valued the progress he

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had made and did not want to jeopardise his possible discharge to an open ward nearer his home. ‘I seethe,’ he said jokingly, describing a bubbling anger just simmering beneath the surface, but not the raging torrent that had previously threatened to engulf him. Philip said he felt calm and relaxed when he drew, and that he had appreciated having someone to listen to him. With enough trust and strength to take risks in testing the containing abilities of the therapeutic environment, he had found art therapy capable of holding his most vulnerable and terrifying emotions. Through the non-verbal processes of image-making, Philip had become conscious of earlier experiences before those which aroused the anger that overwhelmed him and led to his offence. Philip described his last image (Figure 7.6) as a landscape with trees, a fence and a burning bush in the background. The entire image is brightly coloured with a vivid orange dominating the background, suggesting he had achieved some control and distance from his rage.

Figure 7.6 Philip: Landscape.

What I have described is only one aspect of the work with Philip. Looking back over his pictures, it was evident that Philip’s images changed from dark and menacing to lighter and softer. I wondered what this indicated for him.

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Perhaps it showed a change in self-perception, or his ability to take something good from the therapy, which he had initially rejected. Philip’s view was that he got better at art and his drawing skills improved.

Conclusion In some cases, including that of Heather, therapy does not even remotely touch the anger, as aggression is externalised to such an extreme extent that the patient only experiences feelings outside themselves and only rarely, if ever, internally. For violent offender patients, reconnecting with anger can be extremely anxiety-provoking and overwhelming, unless held safely. Insight into root causes of anger and aggression, apparent in acting-out behaviour, may gradually develop by staying in art-making, long before anything can be discussed or meaning sought and, in concurrence with Rabiger (1990), by avoiding assumptions of symbolic content in patients’ work. Art-making as a therapeutic endeavour may provide an intermediate stage in the process of creating a safe container for incomprehensible feelings to surface, and can help thinking to take shape and risks to be worked with over time. Through the case examples of my work in prison and secure settings, I have described a process of containment where feelings can be revisited and reworked through use of art materials and image-making, to gain meaning in seemingly irrational acts of murderous and humiliated rage. Returning to my original point, the patients I work with have not developed a capacity to symbolise murderous feelings, but have acted concretely on their anger, hurt, pain, paranoia and other feelings. The process in art therapy provides an intermediate space, giving rise to an opportunity for a corrective or reparative experience. Through holding and containment, offender patients can work towards the next stage: play, symbolisation and risk-taking. They can feel angry and ‘as if ’ they could murder someone, without the need to act this out in reality.

References Bowlby, J. (1988) A Secure Base. London: Routledge. Freud, S. (1964) Civilization, Society and Religion, Group Psychology, Civilization and Its Discontents and Other Works. London: Penguin Books. Levens, M. (1989) ‘Working with defence mechanisms in art therapy.’ In A. Gilroy and T. Dalley (eds) Pictures at an Exhibition. London: Routledge. Rabiger, S. (1990) ‘Art therapy as a container.’ In C. Case and T. Dalley (eds) Working with Children in Art Therapy. London: Routledge.

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Teasdale, C. (1995) ‘Reforming zeal or fatal attraction: why should art therapists work with violent offenders?’ Inscape 2, 2–9. Williams-Saunders, J. (ed.) (2001) Life within Hidden Worlds. London: Karnac Books. Winnicott, D. W. (1971) Playing and Reality. London: Penguin.

Further reading Aulich, L. (1994) ‘Fear and loathing: art therapy, sex offenders and gender.’ In M. Liebmann (ed.) Art Therapy with Offenders. London: Jessica Kingsley Publishers. Dalal, F. (2002) Race, Colour and the Process of Racialisation: New Perspectives from Group Analysis, Psychoanalysis and Sociology. London: Brunner–Routledge. Symington, N. (1996) ‘The origins of rage and aggression.’ In C. Cordess and M. Cox (eds) Psychodynamics and the Offender Patient. London: Jessica Kingsley Publishers. Winnicott, D.W. (1986) Home is where we start from: Essays by a Psychoanalyst. London: Penguin.

Chapter 8

Avoided Anger: Art and Music Therapy in a Medium-secure Setting Simon Hastilow and Terri Coyle

Introduction Anger is a part of everyday life: for many people it is an emotion, for some it is a form of self-expression. This study is an exploration of what anger meant in the context of two therapists working with one client, whom we refer to as Toby, a man in the grip of murderous rage that he found difficult to acknowledge and express on a conscious level. Instead, he expressed his anger by setting fires and harming himself. We look at how we attempted to provide an environment where Toby’s anger could be expressed and explored in a safe way. We look at the way that Toby engaged with art and music therapy, and how his relationship with us developed, especially after a decision was made to move him to another unit. This chapter is based on the process notes and recollections of both therapists, but was written by Simon Hastilow with input and support from Terri Coyle.

The client and the context To maintain confidentiality we have changed Toby’s details. Toby was a white man in his fifties, the younger of two sons, with parents who remained married until parted by death five years ago. Toby’s father died first, followed a couple of years later by his mother. His father worked as a docker until forced into early retirement by an accident. The family history was blighted by poverty and alcoholism. The boys were sent to a boarding school for a brief period, the reason for which was never made known to Toby. The boys hated the school and after various escape attempts were sent home. 134

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Toby was labelled a ‘slow learner’ and there were suspicions of learning difficulties (although this was not substantiated by psychometric testing undertaken as an adult). Toby’s educational experiences were similar to those identified as common features for arsonists (Smith and Short 1995, p.137): ‘Adverse early experiences and childhood institutionalisation, together with poor education and employment records, are commonly found.’ He left school with no formal qualifications but did manage to find a job. Just as Toby was beginning to establish himself in his new post, his father had an accident, falling from a crane whilst under the influence of alcohol. Consequently, Toby left his job to support his mother. The family’s financial situation declined sharply. Toby acknowledged that there was poverty but maintained that his parents always did their best for their sons. We felt that, despite his parents’ intentions, the boys would still have been affected by poverty. Other therapists have identified this as an issue: ‘Although the link to past traumatic experiences is now almost universally accepted, it is my belief that deprivation has an important place alongside sexual, emotional and physical abuse’ (Delshadian 2003, p.71). From his late teens Toby found himself in trouble with the law, usually as a result of being inebriated with alcohol. He first came into contact with mental health services in his early twenties when he received treatment for depression. During the next 20 years he was admitted to hospital on a number of occasions, and was finally sectioned under the Mental Health Act (1983), after getting drunk and setting fire to his parents’ house with them and himself inside. No one was hurt, but there was minor damage to the interior of the property. Toby gave no reason for his actions and was referred to hospital for treatment. The court ruled that he had diminished responsibility owing to mental illness. Toby was sent to a medium-secure unit because the arson had endangered human life. Toby came across as friendly, but it felt as if he was presenting a persona who was easy to be with but perhaps superficial. He denied feelings of anger or frustration towards other people, but admitted feeling disappointed and frustrated with himself. There were visible signs of self-mutilation, with deep-looking scars on both his forearms. The excessive intake of alcohol seemed to be a means of drowning out painful feelings, but it became apparent that, at a subconscious level, Toby drank to get in touch with feelings he was unable to express when sober. Toby was referred for art therapy to see whether this might be a medium he could engage with. Initially, he came to a group but moved to one-to-one

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sessions when the group ended. Toby was guarded in his verbal interactions but engaged with the art materials. A year or so after starting art therapy, Toby approached the music therapist and asked if he could attend sessions. This was shortly after his mother died and he wanted help with bereavement. It was evident in the assessment that he talked openly to the music therapist. This was in contrast to his verbal interactions with everyone else. We were interested to see how he would use the two media, and how the relationship with the two therapists would differ. We felt it was important to communicate together regularly, so we arranged weekly peer supervision sessions in which we explored the themes emerging in the work with Toby. This chapter focuses on a summary of the non-verbal and verbal themes that came up in both therapies. After Toby had been in therapy with us for two to three years, the team decided to move him to a long-term unit. Although the team recognised that Toby was making progress in therapy, it was felt that his needs would be met more appropriately in a unit set up for long-term work. We were ambivalent about the move but hoped it would provide an impetus for Toby to allow himself to explore feelings he may have had when his parents sent him away. One of our concerns about the impact of the decision was that it could increase Toby’s suicide risk. The literature confirms this view, seeing arson as ‘an expression of dissatisfaction with the environmental changes imposed upon patients as a consequence of deinstitutionalisation’ (Jackson, Glass and Hope 1987, p.178). Toby was unhappy about the decision. The other unit was in a rural location, 20 miles outside the city, making contact with his brother difficult and visits to his parents’ graves improbable. The move also meant the end of his art and music therapy, with little prospect of similar psychotherapies being available in the new unit.

Work done before decision to transfer Use of the non-verbal medium Looking at Toby’s use of the non-verbal medium in art therapy at this time, the predominant subject matter was buildings. Toby worked on drawings of large buildings using a pencil and a ruler, often working on the same image for several weeks. The buildings had a municipal look and could have been schools, libraries or hospitals. Often the buildings were complicated, with many floors, windows and staircases. Toby became preoccupied with ‘getting things right’, sometimes re-drawing one element several times. He said he had learned to be persistent, rubbing out and re-drawing rather than

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tearing up an image that had gone wrong. As therapists we thought we might welcome Toby doing something as spontaneous as tearing up a picture! Sometimes Toby would use other media, such as paint or pastels, and the subject matter would be different: abstract geometric shapes or landscapes with trees. These were produced at a time when Toby came to the group and seemed to be influenced by what other people were doing. Toby used the non-verbal medium in music therapy most in the early months of therapy. There was a range of musical instruments available to him, including a piano and percussion instruments such as drums, xylophones and so on. His playing was tentative, very gentle, but also creative – he was unafraid of atonal sounds. However, Toby’s musical language felt detached from emotional expression, with no affect. One of the significant differences between this medium and the art therapy was the opportunity for the therapist to improvise alongside Toby. We felt this enabled him to feel more comfortable with the therapeutic space and facilitated a different attachment to each of the two therapists. When Toby did use the instruments it was usually for a short period of time in the session. He stopped using the instruments after his mother’s death. We wondered whether he found the intimacy of shared improvisation too painful to bear, making him more conscious of the loss of his parents.

Self-harm Toby engaged in several forms of self-harm. The scars on his body indicated previous self-mutilation and accidents incurred whilst drunk. On one occasion he absconded from the unit, went on a drinking spree and returned with a serious injury to his leg that he could not account for. He dismissed our concerns that he might have died. This incident took place immediately after a music therapy session where it had become apparent that the drinking, self-mutilation and arson were closely linked. Toby had described himself as feeling ‘isolated, powerless and overwhelmed by problems’ when he first started to drink heavily. By not using the instruments Toby may have found the interpersonal relationship too challenging at times, with limited resources to mediate between him and the therapist. The link between self-harm and arson is a complicated one, which other therapists see as a key feature in therapy: A progression towards health would be for the abused individual to move beyond the frustration of only communicating within the

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boundary of their body through self-harm and move towards aggression directed at the ‘other’ rather than punishing the self. Externalising the rage or conflict through fire setting is an important step. (Delshadian 2003, p.74)

We feel that a move from self-mutilation to arson is indeed a development in how someone expresses themselves, but are unsure as to whether it is a progression or a regression, as much depends on the individual circumstances.

Talking about drinking On the rare occasions when Toby talked about drinking in art therapy, it was usually a reminiscence of an excessive drinking session, going into detail about what he had drunk. He minimised the risks he posed to his health and safety, and denied he was an alcoholic. Toby had specific criteria for defining alcoholism. He acknowledged that his father drank a lot, but did not think of him as an alcoholic. He did, however, describe his grandparents as alcoholics. When asked what the difference was, Toby said that his grandparents were violent when intoxicated. He found it difficult to talk about how drinking was connected to his fire-setting. He sometimes said he could not remember what happened. At other times he admitted he could remember thoughts and feelings but did not want to talk about them. This was a contrast to Toby’s behaviour in music therapy, where he could recall crying, smashing windows, vomiting, self-harming, having suicidal thoughts and setting fires. When asked about these expressions of anger, Toby said he got angry with himself because he let himself down. In one session he said, ‘Something clicks and I get fired up.’ The function of alcohol in relation to arson is picked up in clinical studies looking at common features of arsonists: ‘Disinhibition probably also plays a major part in much firesetting behaviour, as 38% of arsonists were found to be intoxicated when they set the fire’ (Smith and Short 1995, p.138). Another paper suggests that patients who would not usually be prone to arson, might set fires if intoxicated: ‘The use of alcohol may remove inhibitions against firesetting in psychiatric patients with other primary disorders’ (Geller 1987, p.503).

Distancing as a defence Toby had a particular facility for talking about people and events in a way that distanced him from the feelings involved. When talking about visiting his parents’ graves, he ended up going into detail about the buses he had to

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take. Sometimes the use of detail made it hard for the therapist to focus on what might be contained within or behind what was said. Detail filled spaces where feelings could have been, as in his drawings. In music therapy Toby began to tolerate pauses and silences. The emergence of spaces created opportunities to bring feelings into sessions. One approach was to name feelings that were not being expressed consciously. In one session Toby recounted how his family did not visit, nor did he hear from them when he wrote to them. The therapist commented that this was very sad. Later, Toby said to another member of staff that the therapist had been in tears, which she had not. We felt Toby was unable to experience feelings for himself and could only acknowledge them if projected into someone else.

Work done after decision to transfer Bringing feelings into the artwork Notable changes in art therapy were a shift in the use of materials and a marked change in subject matter. Toby stopped drawing buildings, although he did produce some images of doorways. He made several images using chalk pastels instead of his customary pencil and ruler. In some images he combined materials. There was an image Toby worked on over a couple of art therapy sessions shortly after the decision to move him. The picture was done using chalk pastels and started as a landscape with the sea in the foreground. He described it as a ‘glorious’ mess. In another session he said that pastels were messy, describing the results of their use as a ‘delightful’ mess. Toby was referring to the fact that pastel dust had got all over the table, up his arms and onto his clothing. The therapist commented that mess could be seen as proof that he had been in the session. In supervision we thought about the use of the words ‘glorious’ and ‘delightful’ as attempts to describe a feeling, and wondered whether Toby was beginning to be able to see his feelings and their expression as something positive. He added a long, low shape within the landscape using a ruler and a pencil, and coloured it brown. He said this was a sea-wall to prevent flooding. In supervision we wondered whether Toby was seeking to regulate his own potentially flooding feelings, recognising their potential for destruction. Whilst working on the image Toby talked about a trip he had made to the cemetery. His brother was supposed to meet him there but had not turned up. Initially he seemed to accept this as

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something he had suspected might happen, but went on to acknowledge he felt upset. The ability to be more spontaneous with art materials was at its height in the penultimate art therapy session. Toby started a chalk pastel drawing (Figure 8.1) by putting a wiggly line down the page. He adapted this into a drawing of land and sea. This was different from his earlier seascapes. First, he had adapted it from an initial squiggle, where other pictures seemed planned. Then he used more colours in the sky and sea, making them seem alive, stormy even. When the therapist commented on this, Toby began to add red to the sea, saying he wanted it to look even stormier. This was exceptional for him, adapting an image to heighten its communication of affect. Looking at the image, the viewpoint is ambiguous. The area where Toby added red looks as if it might be the sky; the picture also looks like an aerial view of the sea and coast. This ambiguity could be a reflection of Toby’s own ambiguity about his feelings. In music therapy Toby continued to use words as his sole means of communicating.

Figure 8.1 Toby: Picture 1.

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Self-harm and suicidal thoughts As the date for moving came closer, the theme of suicide came up in several art and music therapy sessions. In one art therapy session Toby talked about whether he might try to jump from the car while being transferred to the other unit, as a means of escaping. He said he probably would not because it would be dangerous. Nonetheless, he clearly had suicidal thoughts about the move. When talking about Beachy Head in response to the seascape he had produced, Toby said it was a dangerous place because so many people had jumped off the cliffs. He said he thought the area should be fenced off for public protection. Although, on the face of it, Toby was referring to death and suicide, the underlying theme was making things safe. Some clinical studies have looked specifically at arson as a means of suicide: ‘Twenty percent of the fire setters (62 out of 304) had made serious suicide attempts, and sixteen percent (49 out of 304) had slashed themselves prior to the fire-setting episode’ (Repo et al. 1997, p.304). The issue of jumping from the car came up again, with Toby asking the art therapist if he thought he would be hurt jumping from a vehicle travelling at 60 to 70 miles per hour. It felt as if he was testing the therapist’s concern for his safety. The therapist said he thought such an action would be fatal. Toby said he would not kill himself that way because there were less painful ways, should he want to do this. He said going to the other unit was like jumping out of the frying pan into another frying pan. It was unusual for Toby to use a metaphor to describe his circumstances, indicating that he had developed his ability to reflect on his emotional experience. When asked why it would not be like jumping into the fire, Toby said that would mean death and he did not want that. It was interesting that when it came to fire, his metaphor became more real to him. Suicide was also a theme in music therapy. Toby brought up the subject of discovering a patient who had fatally hanged himself. He talked about suicide as a selfish act, in which people did not think about the effect on their family. We felt Toby was thinking about the matter at a deeper level, perhaps thinking about the impact his death would have on his brother. In one music therapy session Toby related a childhood incident of being disciplined by his parents. He remembered being slapped and sent to his room where he cried on his own. This reminded the therapist of things he had said previously about how he felt when self-harming, that is, lonely, sorry for himself, that he had made a mess of things, but also that he did not

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deserve what he had been handed in life. The therapist explored with Toby the possibility that there might be a link between how he felt when self-harming, usually on his own, and his past experiences of being punished. Toby denied any connection, but we wondered whether the therapist’s comment would enable Toby to think about the possibility of a link for himself.

Changes in talking, letting down the defences Toby became more able to be direct in his communication with both therapists, but it was more marked in music therapy. With the art therapist he still tended to talk about things in an indirect way. In one session Toby talked about members of the occupational therapy department, especially a person who had worked closely with him for three years before moving to another job. He said he felt trusted when he was with them. On the face of it we felt he was processing the thought of leaving the unit himself. He seemed to be acknowledging the loss of his previous occupational therapist, and, on some level, might have been contemplating the loss of his art and music therapists. We also felt he was making a comment about not feeling trusted by the team, hence his referral to a long-term unit. The occupational therapist came up in music therapy in a more poignant form. Toby talked about her leaving and his anxieties about having to get to know new staff. He then spoke of a couple in the Guinness Book of Records who were married for 83 years. There seemed to be multiple connotations here: the loss of the long working partnership with the occupational therapist; the forthcoming loss of the art and music therapists; and the loss of his parents. The therapist asked Toby if he ever cried over the loss of his parents. He said he had not, but he thought he would cry if anything happened to his brother. In another art therapy session Toby acknowledged he had been feeling frustrated with the system for keeping him detained. He then said that he felt angry with the psychiatrist. This seemed highly significant. Not only had Toby identified a feeling, he was able to identify that he felt angry with the psychiatrist specifically. This came up in music therapy, too, but more directly. Toby said he felt it was the psychiatrist’s fault he was being transferred. Locating these feelings in an individual seemed like a progression from locating them in an institution. He said it was disgusting that he was being transferred.

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Drinking and feelings In the very last art therapy session Toby said he had been asked if he wanted anything specific for a leaving present. He said he wanted a bottle of cognac, but as that would be too expensive, he would make do with a bottle of whisky. The therapist asked Toby whether he would be able to talk about the ending if he had been drinking whisky. Toby said he would, but he would probably get very emotional. He said he knew the feelings were there but they only came out when he was drunk. When asked what he might say if he was drunk, Toby changed the subject. With music therapy we noted that in Toby’s earlier sessions talking about feelings was usually accompanied by talking about drinking, that is, as a means to avoid feelings. In his last few months in therapy the music therapist noticed that Toby could talk about feelings without also talking about drink.

Processing the ending In one art therapy session Toby started a picture (Figure 8.2) of two arched shapes, using a ruler and a cup (to draw round to form the arches). He described them as gates, but they looked remarkably like two graves side by side. Toby talked about being sent to boarding school, but the reasons for this were never explained to the boys. Toby denied any curiosity about his parents’ decision, saying they were not there any more to ‘defend themselves’ (that is, give their reasons). We felt this indicated that he did have thoughts and feelings on the matter, which he was unwilling to explore for some reason. In supervision we looked at the shapes as both a gateway and as graves. As a gateway they could represent transition or a barrier, or both, to hold feelings in and keep people out. As graves they could represent a metaphorical death or ending (two graves – two therapies coming to an end). They might also represent his parents’ graves. Talking about boarding school could have parallels with being ‘sent away’ by the team. We felt that Toby was unwilling or unable to process his feelings about his parents sending him away, but would have an opportunity to work through his endings with us before he left the unit. One of the art therapy sessions took place in another room because building work was being done in the usual room. The change of rooms had parallels with the impending change of unit and brought about some interesting interchanges. Toby complained about the fact that the materials

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Figure 8.2 Toby: Picture 2.

available were not the same as in the other room. The new room was also a place where clay was stored. He said we could use the clay to throw at each other. Although this was said in jest, there was an undercurrent of hostility in the suggestion. Whilst welcoming this as an expression of anger, it was difficult to find a way of commenting on it, so it was noted by the therapist but not interpreted in the session. Towards the end of the final art therapy session the question came up as to what to do with the images produced. Toby asked if they could be sent on to him at the new unit. He said he would have a bonfire and burn them all. In supervision we felt that this was like his criminal fire-setting, where he wished to obliterate all the painful and difficult times in his life that were unbearable. The difference in this case was that a bonfire could have a similar symbolic significance but in a form that was safe. Toby spent a lot of time in music therapy thinking about leaving the unit. He had been going through the work he made in pottery and woodwork, wondering what to take with him. He said there was nothing he wanted to take and that being in the unit had been awful. He said he could not go

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anywhere in the evenings, ‘It’s not like I can go home and have a three-course meal and a glass of wine’. The music therapist said she wondered whether Toby thought she did that, and whether Toby believed he was not thought about outside the therapeutic relationship. Toby denied that his comments related to the therapist, but moments later said she was the only person who cared. In another session he said he had been ‘crying out all his life and no one listened until you’. This reminded the therapist of when Toby described himself as screaming and wailing when drunk. We thought of him as being like a raging baby left to cry and not being held. It seemed significant that Toby was able to think about his relationship with the music therapist and recognise that there had been a different response to his cries for help. Toby asked the music therapist if she would be working with other clients once he had gone. This could be seen as expressing a fantasy of being forgotten when he left. When it came to the last art therapy session we were convinced that Toby would be asleep or would avoid the session in some other way. In the end we were right, and wrong. Toby was awake, but said he did not want to have a session. He asked if we could go for a cup of tea instead. This was agreed because it felt important that he had been able to face the ending without avoiding it altogether. It felt like his way of being in control in a way that was effective without being dangerous.

The therapists, the team and family parallels In supervision we explored who we, as therapists, had become for Toby. We explored the feelings that we brought up in Toby, and the feelings he brought up in us. At times it felt as if the music therapist had become a maternal figure for him. The relationship with the art therapist seemed more fraternal than paternal. Our fantasy was that Toby saw the psychiatrist as a paternal figure, with whom he could feel angry. We felt that making the referral to the long-term unit changed the way Toby related to us in the sessions and had strong echoes of his experience of being sent to boarding school. The referral confirmed Toby’s belief that we would reject him. We felt that once his worst fear was confirmed, he was free to explore how he really felt about it. Toby was able to acknowledge that he felt angry with the psychiatrist but not able to make the link between this and his feelings about his parents.

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Learning from experience Looking back it is possible to think about the treatment Toby was offered and to see where the gaps were. The literature on treating arsonists indicates that patients like Toby should be offered a range of opportunities to boost their sense of self-efficacy and self-esteem, including focused group work: ‘Social skills training would profitably target communication skills, assertiveness training, and problem solving skills which would foster a sense of self-efficacy’ (Stewart 1993, p.254). Toby did not have access to assertiveness training, nor was there a psychology group catering specifically for arsonists. We wonder whether he would have benefited from the peer support such a group might have provided. There was the possibility of Alcoholics Anonymous, but Toby denied having a drink problem. However, Toby did have access to a range of educational and vocational groups. He particularly enjoyed pottery and woodwork where he could make things for people. Most significantly, after years of therapy with us, he made a wooden cross for his parents’ graves, and this played a huge role in facilitating his ability to grieve for them. The literature also recommends being given a space where the psychological processes of arson can be explored, which Toby had in the form of art and music therapy.

Conclusion Referring Toby to another unit enabled him to develop his engagement in both art and music therapy before the move took place. His use of art materials seemed to loosen up, with more colour, more mess and a development in the subject matter. The artwork became more communicative of affect, culminating in the image of the stormy sea. In music therapy, Toby continued to rely on verbal interaction and began to make tentative connections between childhood events and self-harm, although he did not make a conscious link between the transfer and being sent to boarding school. He used both therapies to process suicidal thoughts arising from the decision to move him, also to explore the loss of the therapists and feelings of anger about being transferred. In this way he had the opportunity to process the ending of the therapies.

References Delshadian, S. (2003) ‘Playing with fire: art therapy in a prison setting.’ Psychoanalytic Psychotherapy 17, 68–84.

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Geller, J. L. (1987) ‘Firesetting in the adult psychiatric population.’ Hospital and Community Psychiatry 38, 501–506. Jackson, H. F., Glass, C. and Hope, S. (1987) ‘Why are arsonists not violent offenders?’ International Journal of Offender Therapy and Comparative Criminology 31, 175–185. Repo, E., Virkkunen, M., Rawlings, R. and Linnoila, M. (1997) ‘Suicidal behaviour among Finnish fire setters.’ European Archives of Psychiatry and Clinical Neuroscience 247, 303–307. Smith, J. and Short, J. (1995) ‘Mentally disordered firesetters.’ British Journal of Hospital Medicine 53, 236–240. Stewart, L. A. (1993) ‘Profile of female firesetters. Implications for treatment.’ British Journal of Psychiatry 163, 248–256.

Part III

Mental Health

Chapter 9

The Role of Anger in Women who Cope by Self-harming Camilla Hall

Introduction This chapter draws on material from five years’ work running groups for women in the community who cope by self-harming. The groups were facilitated by Sally Baldwin, a psychotherapy colleague, and I, and were a joint venture between Social Services and the National Health Service (NHS). Each programme was of 12 weeks’ duration, with the opportunity of joining a ‘graduate’ group for those who were able to engage in longer-term work. Referrals were received via psychiatry and through community mental health teams. The groups were structured to take into account the psychopathology of a client group whose behaviours have developed to cope with memories and emotions that could not be thought about. The programme consisted of a psycho-educational or support component followed by an art therapy component. The psycho-educational section included statistics, fictional case studies, relaxation techniques, anger diaries and questionnaires on core beliefs. The charts (containing information about self-harm and its underlying causes) and the art work served as transitional objects that enabled the women to connect with the roots of their self-harm in an oblique way without being overwhelmed or withdrawing. In this way a pattern of connection and retreat was respected, and women were able to recognise their internal states and begin to generate links to their early childhood experiences. A consistent theme in these groups has been the link between anger and self-harm. Women have explored how past and present experiences of feeling invalidated, abused, uncared for, envious, frustrated and exploited have generated terrifying rage. The women’s fear of what they might do with 151

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these feelings had necessitated withdrawal from others and the physical enactment of self-harming. With reference to relevant literature, and through two clinical examples, anger in this context is explored and related to a particular type of relationship where rage defends against overwhelming loss.

Definitions of self-harm Self-injury is defined by Favazza (1998, p.259) as the ‘deliberate, non-suicidal destruction of one’s own body tissue’. Walsh and Rosen (1998, p.10) add that it is bodily harm of a ‘socially unacceptable nature’, which distinguishes it from culturally sanctioned practices of self-harm, such as piercing and tattooing, and other healing, spiritual and order-preserving rituals. When it is perceived as individualised and lacking in aesthetic value or ritual significance to the community, self-harm is generally considered pathological and responded to with incomprehension and a lack of sympathy. Turp (2002) introduces the idea of a continuum of behaviour from ‘good enough’ self-care to severe self-harm. She includes self-neglect as ‘self-harm by omission’, such as self-imposed sleep deprivation or overwork. In my own work self-harm denotes deliberate physical attacks on the body, not with the intent to commit suicide, but to represent psychic wounds and internalised processes. The behaviour of most of the women who attended the groups would include a range of neglectful and harmful acts.

Theoretical perspectives Identification with the aggressor Identification with the aggressor is a defence mechanism identified and described by Anna Freud (1946) that has helped me to understand the patterns of interaction that group members engaged in. According to her, when faced with an external threat (criticism from authority, verbal or physical violence or abuse), the person identifies herself with her aggressor. In her opinion, the mechanism is a progressive development, with the aggressor being absorbed whilst the feelings of being attacked, criticised or guilty are pushed out on to someone else. The criticism is then incorporated into the super ego and generates an intolerance of others and is a preliminary phase of developing morality. True morality begins when the internalised criticism, now embodied in the standards exacted by the superego, coincide

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with the ego’s perceptions of its own fault. The subject becomes less intolerant of other people but has to endure the displeasure created by self-criticism and guilt.

Attachment and mentalising Many of the women attending the groups had histories of avoidant and disorganised attachments with caregivers who had been inconsistent, had failed to protect them and had been emotionally unavailable. A useful model for the transmission of secure attachment has been delineated by Bateman and Fonagy (2002). Mentalisation is the ability to perceive and understand mental states (thoughts, feelings, desires, beliefs). They propose that the availability of a reflective caregiver increases the likelihood of the child’s secure attachment and facilitates the development of theory of mind. The process is intersubjective: the child gets to know the caregiver’s mind as the caregiver endeavours to understand and contain the mental state of the child. Bateman and Fonagy (2002) go on to say that a failure to internalise this function leads to a desperate search for alternative ways of containing thoughts and the intense feelings they evoke. They suggest that, in cases of a hostile, abusive or absent relationship with the caregiver, the infant may turn away from the mentalising object because the contemplation of the object’s mind is overwhelming because of its hostile intentions towards the infant’s self. This was a helpful concept to understand the avoidance of mental states exhibited by group members and their anxiety about establishing links with an understanding object.

Clinical examples Maureen Maureen was referred to the group by her community mental health nurse. She was 61 years old and had retired from her job as a care worker with disabled children. She had been an active member of her community in the past, organising events for older people and helping to build a community centre. Maureen was the second of eight children, and described herself as having ‘the best parents in the world’. She said that she had had a very happy childhood. Her father had served in the Second World War, and on his return the family moved to Ireland, where her father’s family originated. Maureen

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was subsequently educated in a convent where she was discriminated against for being English, and subjected to physical violence by the nuns. Maureen later married and had a daughter; she then adopted a baby son and later had a son of her own. Her adopted son was in trouble with the police from the age of 15 years. Later, his drug addiction to heroin led to regular police raids on the house. Her son had persistently stolen from Maureen and damaged their home; she recalled the ‘wheely bin’ being smashed through a window 14 times in three months. Repeated damage to her property had created antagonism with neighbours and the housing association, with whom she had many disputes. Maureen found the courage to take out an injunction against her son, but he took money from her at knifepoint and abused her in the street. After 33 years of marriage her husband moved out, as he could no longer tolerate the situation; however, he remained supportive. Maureen started to self-harm by cutting her legs with a Stanley knife; she said she ‘was trying to move the pain from her heart’. She felt terrorised and trapped by her son, and saw herself as ‘not having the male power like her husband’ to defend herself. In dialogue with other group members she mused that using a Stanley knife might link with her son’s use of blades as part of his drug habit, and perhaps a re-enactment of being robbed by him at knifepoint. She said that her husband’s departure had felt like abandonment, and connected this event to the start of her self-harm. In the group Maureen was often physically agitated and found it difficult to keep her hands and body still. She linked her regular headaches and her high blood pressure to her intense anger. In the art therapy sessions she usually folded her paper and made a collection of doodled and unconnected images of boxes, stick figures, devils and ‘fat cats’. She dismissed her two-dimensional outpourings as ‘nothing’ and appeared more satisfied when she produced turtles and tortoises in clay. Initially, Maureen told the group about her need for privacy around her self-harm, which had been reinforced by incomprehension of her behaviour from her family and hostility from nursing staff when seeking treatment. To her community nurse she presented her self-harm as deriving from ‘accidents’. She explained to the group that she currently used superglue on her cuts or stitched them herself with nylon thread. She told us that a neighbour who had caught her stitching a wound had subsequently gossiped about Maureen, telling others that Maureen ‘was mad’ and this had exacerbated already strained relationships. Group members responded with their own

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stories of rejection when they had made disclosures of self-harm. One group member suggested that the thought of Maureen stitching her own wound might serve other group members as an antidote to self-harming in the future. Maureen was intermittently hospitalised when deemed at risk to herself, and was therefore absent from the group. On one occasion she had ‘inadvertently’ set fire to herself whilst stripping a door. On her return to the group she explained that she ‘had to explode with anger not to feel the pain’ indicating that her method of self-harm needed to echo the violence of her experience of being terrorised. Group members expressed their concern for her safety. She told the group that it was the first time she had been able to admit to other people what she was doing, and that this had made it more real for her. She said that for the first time she felt that her self-harm was understood and not judged. In later groups Maureen was able to say that she was constantly angry and that this was in response to injustice. Her rage focused on representatives of the housing association, depicted in her images as ‘fat cats’, and the police, whom she saw as corrupt. She drew images of stick figures and devastated trees but scribbled them out and refused to speak about them. In one session Maureen bemoaned the clearing up she had had to undertake after a fire caused by a chip pan which had ignited. She had covered the chip pan with a wet towel but the fire had gained strength and set alight the kitchen curtains. She made an attempt to quench the fire but had then taken herself to bed in a fatalistic way. A neighbour had called the fire brigade and when Maureen heard firemen downstairs, she roused herself for fear of being ‘carted off to hospital’. She told us that she had previously removed all the batteries from the smoke alarms as they tended to disturb the neighbours, and she was mildly irritated that the fire service had been called. I commented that she must have been in tremendous emotional pain to want to die in that way, to which she nodded. In that session she made a clay figure which she pierced through repeatedly with a pencil. She spoke of the physical and psychological abuse that she had withstood at school in Ireland. At the close of the group, members extracted a promise from her that she would replace the batteries in her smoke alarms, be careful with her gas cooker and that she would attend the following week. For a period Maureen’s husband increased his presence in her home and she talked to the group about how her son had ‘played them off against each other’ and created mistrust between them. A more integrated picture of a

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series of smudged pastel circles replaced her usual discordant and haphazard images (Figure 9.1). The outer rims were in darker hues with lighter yellow, cream and white towards the centre. Outside the circles birds were flying, evoking a peaceful and contained state of mind. My thoughts linked the image with dying and moving towards ‘the light’.

Figure 9.1 Maureen: Moving towards the light.

Indeed, by the next session Maureen had again set her hallway ‘accidentally’ alight and had been sectioned. When she returned to the group she talked about her fury with the housing association, which she felt had betrayed her by breaching confidentiality with a neighbour. She had picketed the housing association offices, thrown stones at their windows and flung 30 silver coins at the worker involved in her accommodation difficulties. The housing association was intending to terminate her tenancy as her fire-setting posed a risk to neighbours. Maureen used modelling material to make a figure personifying rage. The hair was on end, in spikes, and the eyes were bulging. This figure, representing her personality, eloquently captured the experience of her presence in the group – belligerent, agitated and hard to contain.

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During the next few weeks Maureen regularly cut her legs to help her contain her anger and she discussed this in the group. She said that she chose to cut her legs as this was a part of her body that was usually covered, and that it was perhaps an expression of her inability ‘to walk away’. This way of coping helped her discharge her anger sufficiently to negotiate with the housing authority more appropriately, and her suicidal thoughts diminished. She agreed to be rehoused away from the neighbourhood where the legacy of difficulties with her son and more recent incidents were making things extremely problematic. She was then absent for a number of weeks owing to a chest infection and did not respond to any communications from the group. She was therefore discharged. It seemed that the sustained break from the group had broken the link for her and it was too difficult for her to return and continue working. Maureen personified rage in the group and articulated the fear, held in the group, of going mad with angry feelings. The group members’ capacity to accept her anger facilitated her inclusion in the group and being supported by others. She brought the reality of self-harm into the group through her absences when she had hurt herself and through her subsequent frank discussions. She represented the link in the group between anger and self-harm, and between anger and somatisation by her headaches, high blood pressure and evident overt physical agitation. Maureen’s difficulties linking thoughts and feelings were evident in her fragmented images. Her need to create a protective shell and find refuge from her feelings was indicated in the tortoise and turtle models she made intermittently. Her later more integrated image (see Figure 9.1 above) indicated a degree of containment in the group and a reduction in her depression – which then gave her the energy to attempt suicide. The relationship between Maureen and her adoptive son was present in the scenes of devastation she produced and those scenes she scribbled over and annihilated, mirroring what he had done to her. Unable to remove herself from him, she focused her anger on untrustworthy authority figures, such as the nuns who had mistreated her and the housing association officials who had betrayed her confidentiality. Maureen stated that her earliest experiences were positive until moving to Ireland, and that may be the case, or it may be that violence was projected on to the nuns to preserve the good objects in her family. Her parents did not appear to be able to intercede about the abuse she suffered and may have contributed to her internal object relationships which made separating from

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her abusive son so problematic. For Maureen the group had an important normalising function for both her self-harm and her anger.

Samantha Sam was a 40-year-old divorced woman with four children by three different fathers. She had survived an extremely traumatic childhood in which she had suffered physical and sexual abuse, witnessed domestic violence and had no good or positive attachments. She was the fourth of nine children born to her parents. Her father was an alcoholic, her mother was unfaithful and she herself was put into care at eight years old when her parents were evicted for non-payment of rent. These events were compounded by an abusive marriage and by an ex-partner who sexually abused her daughter. Sam presented as depressed with some thoughts of killing herself which she reported she would not act on because ‘she was a coward’. She suffered with pain in her back and shoulder which was being investigated medically and which she felt contributed to her low mood. She was concerned about her difficulties in managing her anger. She said she was often quite impulsive and verbally, if not physically, aggressive with her children. Sam believed that her self-harm helped to regulate her moods and brought her ‘back to reality’ when difficult memories came to her mind. She said that cutting and stabbing herself, hitting walls and taking overdoses enabled her to redirect mental into physical pain which afforded her relief. In the first group session that Sam attended, she arrived a few minutes late, asked for a higher chair in view of her back problems and placed herself on the edge of the circle of chairs. She announced to the group that she was angry and explained that she had just hung out her washing that morning when three workmen lit a bonfire in an adjacent garden. She had shouted and sworn at them, and had threatened to pour buckets of water over it. She told the group that she had been prepared to hit the smallest workman, she did not care about the consequences. Sam said that she found other people irritating; everyone she knew ‘wound her up’. Several group members recoiled in their seats and looked intimidated by her outburst. In the art therapy session Sam painted black circles with her fingers and then added the figures of the workmen in pastel. She derided her production as ‘childish’ but said that she had found it rewarding to do. She said it reminded her of being ‘oppressed by others and escaping into holes’ and that her anger ‘altered her perceptions – she saw people as distorted’.

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However, she could not draw this distortion – her cognitive ability failed her when she was enraged, and her anger seemed to make her perception of interactions and events more persecutory. The next session of the group began with one group member saying how terrified she had been of attending. She said that the group ‘was like going into a room with a tarantula but not knowing where it was’. Other group members elaborated on this simile, saying that they feared disclosing unpleasant parts of themselves in case they were rejected. Sam spoke of having been able to respond differently to her eldest son, with whom she normally fought on a daily basis. She had been able to decide not to escalate the situation and she was surprised at this capacity within herself. She went on to speak of having been sexually abused as a child by a family friend and having, in turn, physically abused her three younger brothers. She said that she had been both the abused and the abuser. She recalled taking a hot poker to her sister and scarring her sister’s legs. She said that she had been bullied and abused in the children’s home and had subsequently decided to fight back and bully others rather than experience the powerlessness she had endured while being abused. Sam said that by abusing others she had ventilated her rage and hurt and made others feel what she had felt. Sam went on to draw a picture of a broom sweeping discarded pencil shavings near a window (Figure 9.2). There were red ‘tears of blood’ drawn vertically down the left side of the picture, a large question mark and the letter ‘Y’. She said that she ‘wanted to sweep the rubbish out of her life’. Her picture seemed more ordered and diagrammatic than the previous one; this might have indicated more capacity for containment, or that she had verbally emptied her ‘rubbish’ into the group. The window seemed to link to the earlier conversation about disclosing unpleasant parts of oneself and the red tears might be her embarrassment. The question mark and the ‘Y’ (why) may have indicated a desire for understanding. Another group member had drawn a series of interconnected cogs, which she said were ‘dry and causing friction’. She said that the ‘cogs represented her self-harm and that it was an issue which required addressing in its various parts’. I asked if it might represent the group, thinking that ‘sparks might fly’, but group members were uncertain. Another woman in the group had depicted her anger and frustration dampened down by cool blue water. She said that she felt a pressure from the group to ‘disclose everything and get it over with’, a feeling I felt might have been inspired by Sam’s revelations.

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Figure 9.2 Sam: Diagrammatic expression.

At the next group session Sam said that she had been furious with the therapists all week. She focused her attack on the group rules, saying she felt patronised to be told that she should not develop relationships with group members outside the group sessions. Another group member commented that it reminded her of the oppressive silence of abusive relationships. Sam dismissed the relaxation techniques that had been suggested during the previous session, saying she ‘didn’t have the time or energy to do something which felt like children’s homework’. She felt insulted. I commented that we (the therapists) seemed to be recreating punitive or controlling authority figures. Sam said, ‘The police have authority but they are no use.’ She had also been upset by the fictional case study we had used for discussion in the more cognitive part of the previous group – she felt it might have been chosen with her in mind. She thought we were trying to ‘f**k her head’. One group member asked whether we knew what we were doing, and another asked if we had information on outcome measures from previous groups. Sam commented, ‘I bet you didn’t expect this today’ and seemed satisfied to have disconcerted the therapists. She said she had known what she was going to draw in the art therapy time from when she woke up, and she proceeded to draw a bomb with the

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fuse lit (Figure 9.3). The bomb dominates the picture and appears to be seconds away from blowing a hole in the brick wall (her metaphor for the rigid authority of the therapists).

Figure 9.3 Sam: The bomb.

Another group member drew her patched-up teddy, an inheritance from her mother; she said drawing it had helped to soothe her as the difficulties in the group had left her feeling shaky. On the other side of her paper she had drawn swollen brain cells with pus inside, related to the headache she now had. Three other members had attempted to draw ‘safe places’ – a country landscape, a beach and a picturesque cottage – in an attempt to contain their feelings. Another group member drew stripes of colour with gold at both ends. When I asked if it might represent the group, someone suggested the gold might be the therapists and someone else queried who the black band in the centre might represent. The remaining image (Figure 9.4) was of a decorative box, rather like a coffin with shapes inside which resembled boxing gloves. Sam said she liked these shapes, which felt as if she wanted to have a place in the group or that part of her had enjoyed ‘the boxing match’.

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Figure 9.4 Coffin with boxing gloves.

As the group closed, Sam said that she felt guilty and hoped she had not ruined the group. No one spoke. Sam said she did not want to come back and one group member told her that it would not be the same without her. Three group members missed the following three group sessions and were offered individual meetings with the therapists, which enabled two of them to return. The group member who had drawn the teddy did not return or respond to any communication. Sam herself continued in the group until its conclusion, and then moved on to individual therapy. In the above example the out-of-control ego state of one group member triggered other people’s destructiveness and made them apprehensive about therapy. Sam’s bomb, representing her anger and subversiveness in the group, was in a sense premeditated (she knew what she was going to draw) and seemed to be a response to experiencing the therapists as controlling but unhelpful parents. She felt patronised by the exercises that were advocated and needed help from the therapists or mother figure to undertake them. Our countertransference in this session indicated what group members were trying to communicate about themselves and the effect of the abusive experiences they had withstood. We felt shattered inside, had no trust in our abilities and we, too, wished to end our relationship with the group. In

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response we tried to receive the anger and criticism in a non-punitive and non-retaliatory way. We managed to survive and acknowledged the difficulties, then in the next session said that we were going to slow down the process of therapy and allow more time to reflect on issues as they were raised. With hindsight, as therapists, we had not responded adequately to Sam’s initial story about wanting to punch the workman, and this left other group members feeling intimidated by her. Her early disclosures destabilised the group, bringing overwhelming thoughts and feelings into awareness prematurely. The muted support she received may have been indicative of the group’s anger that we had not intervened more effectively. Over subsequent group sessions Sam was able to recognise her aggressive exterior as protection for her very vulnerable and fragile sense of self. A later image of a net or petticoat suspended above a ‘black hole’ (Figure 9.5) helped Sam to explore how the absence of a containing mother had left her with a deep depression and rage. The black hole was a repetition of her first marks made within the group and the bomb that she depicted. She saw it as representing her coping mechanism of ‘escaping into holes’ (dissociating), feeling annihilated and feeling consumed with murderous rage.

Figure 9.5 Sam: Petticoat over black hole.

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Sam was very envious of her siblings, who had better relationships with their mother, and we recognised that she probably needed time alone with a therapist or mother figure before she could tolerate being part of a longer-term group. Sam benefited from the group, but at a cost to other group members. For a period she succeeded in reversing roles: her siblings left but she remained. This was disturbing for her as it enacted her fantasy that she could destroy others. As Anna Freud (1946) has postulated, Sam was stuck at the stage of having introjected the aggressor while the feelings of guilt were pushed elsewhere. Witnessing her impact on others facilitated for Sam the experience of feeling guilt. The continuation of the group enabled the experience of both the abuser and the abused to be tolerated and verbally explored, which afforded a degree of reparation.

Concluding thoughts Both women had experienced neglect and this had generated anger, which became frightening to them and was then translated into hurting themselves. Paradoxically, the violence was both a defence against thinking about the past and a repetition of an earlier violation in another form. The fusion of aggressor and victim is likely to be rooted in a primitive identification with a caregiver who could not respond appropriately to the discharge of aggression with containment and care. Both women were victims of violence, intrusion and attacks on their sense of self that could not be thought about or made sense of. Therapy can help to interrupt the compulsion to repeat these experiences, by nurturing a reflective capacity to intercept the destructive impulses and learning to speak of the thoughts and feelings that the act embodies. This is particularly facilitated by art therapy, where a capacity for developing an ‘observer self ’ is enhanced through the image-making; a myriad of contradictory thoughts and feelings may be contained on one page. The images often gave us indications of the core difficulties that underlay group members’ anger, and we could hold these in mind to refer to tentatively later in the therapy. Art-making also offered a means of expression that was cathartic and less damaging to the therapeutic relationship than acting out verbally or physically. Most of the women said that the artwork had enabled them to show aspects of themselves and their experiences that would otherwise have remained hidden.

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In these examples Maureen left the group having made some positive gains, both internally and in her external world. Sam had a liberating, though uncomfortable, experience, in which she shifted position from identification with the aggressor to experiencing guilt and true morality. The group provided material that she continued to digest in individual therapy. The other members who completed the group had the experience of aggression being modulated by art-making and discussion. They discovered that they survived and that fight or flight were not the only options. Anger enabled both these women to face threats, control fear, harness energy and, in some contexts, to stand up for themselves. It helped them to feel active and alive rather than passive and victimised, whilst simultaneously evoking other experiences of being powerless and hurt. If both parts of this experience can be acknowledged and integrated, the potential for interacting differently is possible. Anger provides a powerful recognition of discomfort and is a signal to us that something in our immediate situation requires acknowledgement and possible action. If anger can be recognised and expressed safely it has done its work.

Acknowledgement Thanks to Dr Alberto Albeniz, Consultant Psychiatrist in Psychotherapy, who was the clinical supervisor of this work.

References Bateman, A. and Fonagy, P. (2002) Psychotherapy for Borderline Personality Disorder. Oxford: Oxford University Press. Favazza, A. R. (1998) ‘The coming age of self-mutilation.’ Journal of Nervous and Mental Disease 186, 259–268. Freud, A. (1946) The Ego and the Mechanisms of Defence. New York, NY: International Universities Press. (Original edition 1936.) Turp, M. (2002) Hidden Self-Harm. Narratives from Psychotherapy. London: Jessica Kingsley Publishers. Walsh, B. W. and Rosen, P. (1998) Self-Mutilation: Theory, Research and Treatment. New York, NY: Guilford Press.

Chapter 10

Art Therapy with Cognitive Behavioural Therapy in Adult Mental Health Susan Law

Introduction This is an account of brief art therapy, over an eight-week period. It runs in conjunction with a cognitive behavioural therapy (CBT) element. The CBT takes place over two hours in the morning; the art therapy runs for one and a quarter hours in the afternoon. The subject of the group programme is ‘Overcoming Difficult Emotions’, and it is mostly concerned with anger management. The goals for the CBT part are to: ·

gain insight into personal behaviour

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develop more adaptive ways of expressing anger

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increase ability to have needs met by others

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gain understanding of the difference between aggression and assertiveness.

The goals for art therapy for anger are to: ·

give form and shape to experiences difficult to identify or verbalise

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gain understanding of patterns of anger

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explore where destructive angry behaviours originate

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reflect on how anger affects both personal and professional relationships. 166

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In order to express experience visually, patients have to meet these feelings within themselves and then give them shape and form to put on paper or into clay, thus embodying the feelings in a forum where they can be explored and examined and related to. It is an emotional journey. I work in a private psychiatric hospital. Since 2001 we have developed an anger management course for patients, the majority of whom are referred purely for this course. Our clients are usually funded by health insurance through their work; occasionally, they fund themselves. All of them are under the care of a consultant psychiatrist. Patients are referred to the group in a number of ways. They may be seen by a consultant psychiatrist purely for this problem and referred to the course. They may be seen during assessment for day care in the therapy centre, and go to the group as part of their programme. Or, during the work they do in therapy, anger may emerge as a significant issue that needs attention. Inpatients are not generally referred for several reasons. They are too fragile at that point. They are generally unable to make the funding commitment for an eight-week closed group, during which time they will change status to day patient. Furthermore, there is a lot of demand for the group, so we try as far as possible to ensure we have patients who can see the programme through to the end. As an eight-week group, the programme is not seen as the complete answer to someone’s problems, but it makes a start. The CBT module offers people choices in the way they handle their anger, in responding differently, in giving themselves time to think, in taking a different attitude. The art therapy part explores feelings, gives anger a context, examines patterns of behaviour and accepts some of the painful, shameful emotions which anger defends against. From the ‘Overcoming Difficult Emotions’ group, patients may return to everyday life much better able to cope, or they may go into other parts of our programme to follow up on some of their issues, or they may use it as a stepping stone into further work at a later date. In the following account I will give the title of the CBT subject before I identify and expand on the art therapy theme. The CBT themes are taken from the work of Richard Nelson-Jones in Human Relationship Skills (1990).

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CBT session 1: blocks used to prevent being fully aware of and owning your anger Art therapy session 1: make a picture of your anger The room is prepared in advance: clay, paints, crayons and pastels all placed on two large tables. The first person who comes in expresses his doubts about art and thinks it will make him angry. I encourage him to stay. The group gathers. There are two women and three men. I go through the boundaries of the group: time, confidentiality, responsibility for disclosure (I encourage participants to take responsibility for how much to disclose, to protect themselves), staying in the room if they are distressed or anxious. I also explain that there is no right or wrong about the art process and it may feel strange and daunting at first. I ask participants to bring to the work of the group any feelings that they may have so that we can work in the present on what triggers their anger. The theme of the first session is to describe what anger is like, how it is manifested and how much of the participants’ lives it takes up, that is, why it has brought them here. They think about it and then work quickly. People become very involved with their pictures as they work. Out of this group only one person, a woman, starts with paint. She finds the brush is not enough and starts using her hands with paint, humming as she does so. The others enjoy the fact that she is painting with such freedom. When the group has finished working we meet together in a circle away from the tables and the participants place their artwork on the floor. They talk, one by one, about their work. I encourage everyone to contribute to the discussion, but it often seems that participants can only do this after they have spoken about their work, as if they are absorbed in it, and it is only when they have talked about it that they can let it go and engage with the group. S has written only words on his paper but it describes how his frustration and anger leads to explosion. Until that point he cannot express his feelings. He suffers from fibromyalgia, which leads to pains in his limbs. D has separated from his wife and family, and M from his partner and their family. D feels his anger is too destructive. He lets fly at his two young children at a level they do not deserve. M constantly feels impotent with his anger. He has not got the words for what he wants to say and ends up breaking things at home. Both men are determined to work on their respective problems and retrieve their relationships. Both situations hint of issues with their own parents.

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P has problems with one of her adopted daughters and they are constantly at loggerheads. Her husband is more laidback. We explore the dynamics between P and her daughter. A finds difficulty talking about her work. She is very aware of her troubled life and has had previous therapy, but is finding the emotional connection that takes place in this and other groups painful and gut-wrenching. Her painting is almost completely black. Her past has been horrific, she says, but does not expand on this. She stays behind with me for a couple of minutes at the end of the group while she cleans her palette. The primary aim of the first session is to engage people in the group and, for that, I need to get them to stay. When patient S thinks it will make him angry I do not respond to that statement, but invite him to stay and experience the group. No matter how I describe art therapy, the only way to understand it is to do it, and, beyond that, to share experiences with the others in the group. So I need to capture the participants’ attention from the start by working from where their emotional energy is, and that is what has brought them here, their anger, in all its manifestations. I generally work in a directive way. I aim to make my themes loose enough so that patients can work very freely, applying the subject in whichever way they want. In my experience this in no way stops the unconscious bringing material to the surface. Within the anger group my themes are focused deliberately on a sequence of issues. Initially, when the programme was set up, it was planned as CBT and art therapy. The CBT therapy was to look at the theory and skills training, which included homework. The art therapy was to focus on the emotional issues involved. The idea was that participants would link together, week by week, with the art therapy, picking up on themes from the CBT sessions. I quickly found that I could not work like this: with an imposed structure from outside. I found that I was going against my own sense of the process involved and sometimes against my own judgement. I started working independently of the CBT element although keeping in touch with my co-workers. I let the participants know that the content of the two parts of the course run in parallel and that they will themselves make the connection between the two. And they do. We came to the point where the group was formalised, with a handbook for the participants in which their weekly course inputs were identified. This left me having to define what I would be addressing week by week. In contrast to my colleagues, I have tried to limit my information to a rather

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general idea of what I will do. I reserve the right to move the sequence around as I feel appropriate and to give a final definition on the day. Since affirming my independence of the CBT process I have felt much happier with it. My own confidence in the work I do has developed and, alongside this my sense of holding the group safely. One of the benefits of covering a sequence of topics within a closed time-limited group like this is that I develop some expertise within certain parameters. I find that, for me, it generates excitement and I look forward to each week with anticipation.

CBT session 2: choosing realistic personal rules Art therapy session 2: childhood memories Having had a brief discussion with my CBT co-therapists from their morning session, I choose to explore good and bad memories of childhood. I hear from them that D is doubtful about art therapy. Nevertheless, he turns up. All five patients who attended last week are here again this week. This is the second week, and, if no new person joins this week, the group will remain as these five people. A arrives 15 minutes late. Although the boundary of the group is to arrive within ten minutes of the start, I let her in because I know it reflects her ambivalence about engaging with intensely painful experiences. The doubtful member, D, expresses surprise at the theme, and says that he had been talking at lunchtime about the fact that he had never done anything with his father as a child. I explain that our first experience of how anger is dealt with arises from childhood. Here are our first role models. Here are our first experiences of our own anger and pain, and the ways we learn to protect ourselves. To bring this material into the group at this stage will allow us to make links with it as we go on, if there are links to be made. However, issues with anger may not necessarily start here. Three of the patients this week – the men – describe constant, nasty fighting – sometimes to the point of violence – between their parents when they were children. They do not want their childhood experiences to be inflicted on their own children. D describes his parents as always fighting, although they did not separate. He describes being physically punished, ‘punched around the garden’ by his father for wrong-doing. When D describes an outrageous piece of naughtiness, I realise just how difficult his behaviour was as a young boy. S describes the painful fighting that went on between his parents. It was so unbearable that he cut himself off emotionally from it. He still finds it difficult to spend a lot of time around them. His happy memory was of a

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chopper bike he bought and he realises that it was to get away. He is moved by this insight. In both groups today he is making the connection with his experience, and how it led him to cut off from his feelings. A has made two large abstract paintings. The first is a beautifully coloured painting that describes a time when A can remember a lovely memory from childhood. The second is a dark painting, describing awful memories. A is distressed and talks in more detail about the horrifying experiences, but still says little. P describes walks with her father in the woods. She experienced him as a relaxed personality whose company she loved, not unlike the man she has married. Her mother, on the other hand, was always depressed, unable to show love. P remembers the humiliation of being dragged home by her mother holding her ear. When I comment that as time goes on they will feel more able to share things openly with each other, D’s response indicates his commitment to the group. This session is about childhood memories. I sometimes make this the third session, but more and more I feel this is fundamental to an exploration of my patients’ anger, and the second session is its rightful position as long as the group feels safe enough. Even in the first session, group members often mention their parents or their history, so the material is already present. I find this subject brings hidden history into the arena of material that can be talked about. There is sometimes huge relief in sharing experiences which have never been divulged before, for example, physical, emotional or sexual abuse, abandonment, loss. Often these have been taboo subjects, secrets that have been heavy burdens to carry. There is the relief of opening up painful and shameful memories, and having feelings accepted and understood by others who share something similar. I sometimes feel that this particularly applies to the men in the group. As boys they may have received harsh treatment at the hands of their fathers and may never have talked about it before. What is absolutely necessary is for them to feel that this is a safe place to do so. It is very important that patients have control and are not pressured into any disclosure that they do not want to make.

CBT session 3: perceiving provocations differently Art therapy session 3: a difficult relationship I ask the participants to use clay to give expression to a difficult relationship that they have. S makes three figures: one is seated, two standing (Figure

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10.1). The two standing figures are torsos with arms, but they have no heads. One holds a weapon. S describes these as how he feels about himself in the present. The third, seated figure has an overlarge head on a tiny body. We talk about this as a child-like figure with the head of an adult and relate this to S’s childhood, when he grew up very fast. It makes me think about the lack of childish playfulness and fun in his life. I comment that he needs to be more in his body. I remember the fibromyalgia. His response is about ‘not being able to stand on his own two feet’. He says he needs to think about it.

Figure 10.1 S: Relationship with himself.

D has made his own head looking into a mirror, that is, two heads facing each other through a frame (Figure 10.2). He says he finds the art work difficult. We discuss it in terms of whether he is expecting criticism or judgement himself. He is very self-critical and self-blaming at present. M created two figures, one disproportionately big, and towering over the smaller (Figure 10.3). The larger one represents M’s partner and the smaller one himself. He talks about their arguments and how the positions reverse when he gets angry. These are the only two positions he knows – powerful

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Figure 10.2 D: Looking at himself in a mirror.

Figure 10.3 M: Himself and partner.

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and powerless. I bring in the relationship with M’s father, suggesting that the overbearing figure might also represent his father as he has described him. A did not use the clay. She painted herself and her mother in a ‘Madonna and child’ configuration. She mimics how her mother used to talk to her and how God and the Devil were a constant part of her mother’s discourse. She is endeavouring to find some good in their relationship and notes her ability to sing, which comes from her mother. P used the clay to make the wall between herself and her daughter. She described a recent misunderstanding and is upset because she begins to think that there are echoes of her own mother in the way she relates to her daughter. I find that clay has great power as a medium. If patients can take the risk of using it, clay has the potential to engage them in a very direct way, more so than working on paper, perhaps because of the immediacy of the physical contact. It is ideal for investigating relationships because of its threedimensionality and flexibility. We are looking at anger within a relationship and using the clay to investigate the complex dynamics of this.

CBT session 4: using coping self-talk Art therapy session 4: self-box part I This is a two-part exercise carried out over two weeks because it is time-consuming to do the work. The exercise is to create a ‘self-box’. Participants choose a box from a range of boxes about shoe-box size. It is explained that the box represents themselves. There are a number of surfaces both outside and inside the box, which might represent different parts of themselves. They are to use collage, pictures and words from magazines to cut and stick on their boxes, and it might become clear as they work, whether or how they might differentiate the outside and the inside. Because participants will not find exactly what they are looking for, they may need to be creative with their pictures. It takes time to find appropriate pictures, which is why I allocate two sessions to this task. In the second session I allow about 20 minutes to arrange and stick the pictures, and for anyone who missed the initial self-box session at least to attempt it. It is surprising how much can be achieved in a very short time; sometimes it is a finished piece of work which is presented to the group.

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CBT session 5: using visualising Art therapy session 5: self-box part II I am shocked to discover that two members of the group have not made it to either of the self-box sessions. P explained that she wanted to spend time with her eldest daughter before she goes university. S, it appeared, had dropped out because his insurance cover had come to an end. I did not know this until I followed him up after the session. In addition, it appears that a lot had been happening to M during the last week. The situation with his partner had deteriorated and other information about her activities was coming to light. The outcome of reconciliation looked less hopeful; however, it looked as if the problem with anger was not his alone, but part of the dynamic with his partner. Last week M did not engage with the task as he had to leave the room to make telephone calls to get legal advice. This week, therefore, I ask him to do what he can in 20–30 minutes. Because the group is considerably smaller than I had anticipated I can give more time to completing the boxes. D, M and A are present. The surprising thing about D’s box is that he acknowledges a period of time at school when he was in the army cadets. He says how beneficial this experience was for him, giving him some discipline and direction to his life. It enabled him to make a choice about the focus of his life instead of getting into more and more trouble with the law, as some of his friends did. This relates to what he told me in Session 2, and makes sense. M’s box has a great number of pictures, which represent his two boys. It is clear that he derives great pleasure and satisfaction from being a dad. A has enjoyed making her box and has covered it with a large number of resonant pictures (Figure 10.4). She has a picture of the sky, representing the happy memory she described in Session 2. She has found a picture of the kind of house she would love to have, an ‘A-house’ (a house just for A) where she could write books and make music. Inside her box some of the pictures hint at memories of abuse: footsteps down a long corridor; sepia images of children; the words ‘The Monumental Secret’. To me, the self-box work is about identity. It allows participants to give a wider description of themselves than purely their anger; it can give a more balanced view but it also allows for other more personal material to be acknowledged. It sounds such a simple exercise, but it is often extraordinary and moving in the material people find to represent themselves.

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Figure 10.4 A: Self-box.

CBT sessions 6 and 7: action skills, being assertive, handling aggressive criticism Art therapy session 6: loss and change P and S have not returned. I have spoken to S, but despite telephoning I have not managed to speak to P. Something has happened to A that morning and she does not attend the afternoon art therapy. D and M attend. This session is on the subject of loss and change, two states which are inextricably linked. D chooses to work in clay. He describes his experience of the period after the death of his father-in-law. For some reason his wife, her brother and their mother put D on a pedestal, and he has somehow been given the mantle of the head of the household, over-riding the natural claim of his brotherin-law. The family comes to him for advice and for DIY jobs. Everyone looks up to him. This is shown quite literally in his sculpture (Figure 10.5). D’s own mother also puts him on a pedestal, as the son who has managed to steer clear of problems and make something of his life. This naturally causes a great deal of resentment from his own brothers. He explores this as something that became very difficult for him, and also raises the question of whether it had any bearing on his affair, which led to the separation in his marriage.

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Figure 10.5 D: On a pedestal with family looking up to him.

M has drawn the choice he has about his future, what he loses if he and his partner part company, and what life could be like for him as a single dad. As to the other two members, I have not managed to speak to P. However, she has spoken to one of my co-workers and wants to do some one-to-one work. The ‘overcoming anger’ group was bringing up too many feelings, which she could not manage. She still wants to address them but through a different route. S’s insurance is to be renewed for eight sessions, long enough to repeat the anger group or to find another arrangement of groups which could include art therapy. This session looks at fundamental changes participants have experienced in life and the impact these changes have had on them, both positive and negative. I think people need to have their stories heard, and this attention and discussion can allow a shift of perspective in the present.

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Art therapy session 7: regret and forgiveness There are three people today. A has returned and D and M are present. The first part of today’s title is self-evident. The second part needs some cautionary explanation. I say that I am not expecting that forgiveness is a prerequisite for dealing with anger, but I want the participants to think about the idea and see what it means to them. It may not be something they can offer another person – or it might be. Is it something they might give themselves – or not? In this situation the members of the group can say more to each other than I can. It provokes much discussion in the group. D finds that his wife is forgiving him and they are communicating more. They are not back together again, but are working slowly towards this as they talk. He has some confidence that they may be reconciled. However, D is having a hard time forgiving himself. I refer him back to his figure on the pedestal and note his high demands of himself. A challenges him to forgive himself. A makes a painting of a woman’s face in yellow; purple on one side of her, and, on the other side, deep blue colours. She comments on the strain on the face. A says she cannot forgive at the moment – neither others nor herself. She needs to come to terms with what has happened to her first. However, she is consciously staying with her feelings as they emerge, she says. M regrets the rows which led to the assault on his partner, a night spent in a police cell and a three-month restraining order. He still loves his partner and feels that, ultimately, she is the one with the power to make decisions. What part does this theme play? Sometimes it has offered a real opportunity for participants to let go of the destructiveness in a relationship; that is, the heartache, anger, resentment or despair which they have carried for years. They have been able to see parents doing the best that they could do in the light of their own experience. Sometimes participants have spoken to their fellow group members of their own behaviour, which they have considered unbearable and, through acceptance, have been able to forgive themselves.

CBT session 8: relaxing yourself, managing stress, helping each other to manage anger, concluding self-talk Art therapy session 8: what they have learnt about themselves and how they have changed There are only the two men: D and M.

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D draws a picture of himself, his wife and their two daughters in the park. He and his wife have bought new roller skates for all the family and they are loving it. He is enjoying the contact with his family. On the other hand, he thinks it will be a long time before physical relations will be resumed with his wife, judging by his own response if the situation were reversed. M has seen a solicitor and is encouraged. His situation with regard to separation is better than he expected from a legal point of view. He has loved looking after his youngest child for the last ten days while his wife has been away. He is relaxed and happy, and is not anxious and stressed over his relationship, at least for the time being. It seems as if things have clarified themselves for him. Both men are putting into practice some of the strategies they have learnt and are finding that they work. One of D’s little girls has commented that daddy and mummy used to fight but not any more. M can feel free to walk away from aggravation. They take their art work away with them.

Conclusion The process I have described is a joining of two disciplines, art therapy and CBT, in working with anger. In the CBT element participants are dealing with the nuts and bolts of their angry communication and acquiring, from the beginning, tools to make changes. Their sense of power in dealing with anger is therefore growing at the same time as they are exploring, in art therapy, their history and the situations, events and relationships that have had a bearing on their lives. Participants acknowledge their progress as the course continues. They also frequently express surprise at their involvement in the art therapy after some initial scepticism. The short course of eight weeks reflects the pressure on institutions for quick results, but, on the positive side, allows participants an opportunity to invest this time wholeheartedly to deal with a particular issue. It is vital that this is a safe environment. The process can be rewarding and liberating. It may lead on to further work. It may be enough in itself. It is frequently described by participants as ‘life-changing’.

Reference Nelson-Jones, R. (1990) Human Relationship Skills, second edition. London: Cassell Educational.

Chapter 11

Working on Anger Issues with a Deaf Client Marian Liebmann

Introduction This chapter presents an approach to individual short-term work on anger issues, using a mixture of art therapy and cognitive behavioural techniques. Because the case study involves a deaf client, there were several issues concerning deafness to negotiate. I had not worked with a deaf client using art therapy before, and he had never been offered art therapy and was not sure whether he would take to it. However, despite a cautious beginning on both sides the client was able to use the therapy sessions to learn different ways of managing his anger and frustration. This made a great difference to his life and relationships with others.

The setting The setting for this work was the Inner City Mental Health Team (ICMHT), 1 a community mental health team in inner-city Bristol. The ICMHT caters for a large number of clients from many different cultures and backgrounds. Much of the work with clients is done through home visits, but some clients are seen at the service base, including those for art therapy. At the time of writing, the service base was located within a church hall (the administration section) and a 1960s house, which was previously the manse for a nearby Methodist church. The manse housed the therapy rooms, including my art therapy room, which was medium-sized with a good range of art materials and a view over the garden. 1

Now called the Inner City Support and Recovery Team. The services were reorganised after the work done with this client.

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Referrals to art therapy come from any workers in the mental health system, as well as from primary healthcare teams, and are assessed to ensure that the team only takes on individuals with serious mental illness. The client described in this case study came from the Centre for Deaf People, a city-wide service for deaf people in general, which also included a service for deaf people with mental health problems. All social workers and community psychiatric nurses in the Centre were fluent in British Sign Language (BSL).

Deaf culture Terminology is very important, and is a ‘hot issue’ in this area. For many years deafness was regarded as a disability in the same way as, for instance, an inability to walk after an accident. And some deaf children have been given treatments that have improved their hearing – ear operations, hearing aids and so on. However, these do not help all deaf people. Most medical people still see deafness as a disability, and they try to do all in their power to remedy deafness with operations, hearing aids and speech therapy. In schools the emphasis has been on deaf and hearingimpaired children, being taught to lip-read rather than sign, so that they are able to take part in ‘normal’ society. For many years sign language was not recognised in schools, although it is now being used more. More recently, however, many deaf people have decided that they are not suffering from a disability, but belong to a minority linguistic culture which should be accorded equal status to spoken English (Ladd 2003). Sometimes they do not want their children to have ear operations that might help them hear, arguing that this is discrimination against their minority. They use BSL as their main mode of communication. Most large conferences and many TV programmes now include a BSL interpreter as a matter of course. They therefore prefer to use the words ‘deaf ’ or ‘Deaf ’, rather than ‘hearing-impaired’ or ‘with a hearing loss’. The word ‘Deaf ’ is used for someone who communicates exclusively in BSL, while the word ‘deaf ’ is used for everyone else, and includes those who communicate in writing, BSL, oral English or a mixture of these. The client described in this chapter was born with hearing and went deaf at the age of three, so he could speak but not hear; he used mainly BSL but also spoke English. So I shall use the word ‘deaf ’ throughout the case study (Bristol Centre for Deaf People 2005).

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Art therapy with deaf people The literature concerning therapy with deaf people is not large, but this area is now receiving more attention. It is generally acknowledged that the ideal is to have bilingual workers (Turner, Klein and Kitson 2000), but this can limit the therapies on offer. Higgins and Huet (2000) point out the particular benefits of arts therapies for deaf people because of their non-verbal nature, and O’Rourke (2000) discusses the use of cognitive behavioural therapy (CBT) with deaf clients. Huet (1993) has also written about the skills and attitudes needed in working with deaf clients in art therapy. A more recent article by a Deaf art psychotherapist (Hoggard 2006) emphasises the importance of communication and makes the case for greater accessibility to art psychotherapy for Deaf people via the employment of trained Deaf art psychotherapists. I had worked with interpreters of other languages on many occasions and was used to adjusting my pace and delivery to take account of this. I was therefore hopeful that we could make art therapy work, too – especially as it does not rely totally on verbal communication. One very practical issue was the need for good lighting for deaf people who rely on sign language. Although it is easy to forget to switch the light on as a matter of course, keeping the light on is a common courtesy towards a deaf person.

Cognitive behavioural therapy (CBT) and anger I have been working in the mental health system for several years. Before that I worked in the probation service, as a probation officer, where I helped to run anger management groups for adult male violent offenders. Although the groups were often heavy going, there were quite a few ‘success stories’ of men managing to gain control of their anger, thereby avoiding future court appearances and prison sentences. The groups were based along cognitive behavioural lines, helping offenders to think differently about their offences and to develop new strategies (Novaco, Ramm and Black 2000). The groups ran for eight sessions and included identifying problem behaviour, stages of violent situations, anger diaries, consequences of violence, self-talk, relaxation, assertiveness, verbal and non-verbal communication, review of diaries and planning for the future. Another influence on my work has been the approach of Fine and Macbeth (1992). The authors researched methods of helping young people aged 15 to 25 with techniques for handling their anger and resolving

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conflicts. They produced a manual, Playing with Fire, which uses the analogy of a fire to show how anger escalates from the fuel and sparks to a full-blown fire. They developed strategies to help young people at all these stages.

Art therapy and anger When I moved into mental health work as an art therapist, much of my therapy was aimed at helping people to express difficult feelings of all kinds, including anger. However, my time in probation had convinced me that another important task was to help people deal with these emotions in the right context, rather than visit them upon others. They needed to learn to do this in a way that was not destructive to themselves or others. There were times when all my colleagues seemed to have angry clients on their caseload. About once a week there would be a distressed and angry client in the waiting room banging on the glass window because his or her needs were not being met. There seemed to be a need for anger management groups here, too. As an art therapist I had extra tools, in the form of art materials and the art therapy process, which might side-step the wordiness of verbal programmes and give clients a deeper experience. Furthermore, as already mentioned in the Introduction to this book, art therapy has several particular things to offer in work on anger management. I developed a theme-based art therapy group model using the main ideas from the verbal anger management groups I had previously run. I wrote handouts to go alongside each session for those who found them useful. The programme covered the following themes: 1.

Introductions and ground rules.

2.

Relaxation and guided imagery.

3.

What is anger? (a first look).

4.

Physical symptoms of anger (warm-up). Anger – good or bad? (main theme).

5.

What’s underneath the anger?

6.

Exploring early family patterns.

7.

Anger and its connection with conflict.

8.

Feelings and assertiveness, ‘I-messages’.

9.

Picture review of artwork done in group sessions.

10. Group picture and ending.

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At the beginning of the group meetings I devoted one entire session to the use of several different forms of relaxation techniques, together with guided imagery. At the end of each session I included a short relaxation exercise, both as a method to help with anger and as a way of letting go of any upsetting feelings arising from the session. It also helped participants to practise the relaxation techniques. I ran several groups using this approach and acquired a reputation for dealing with anger problems. Descriptions of these groups may be found elsewhere (Liebmann 2004, 2007). At a point when I was not planning to run a group, however, I began to receive more referrals. Rather than make these clients wait for a considerable time, I decided to adapt the group material for individual therapy sessions. When I work with individuals on anger issues, I usually offer them the group themes listed above as possibilities for choosing what is most relevant for them. They can select themes, in whichever order seems most appropriate, to help them look at the ‘burning issues’ of the moment. Whenever it seems relevant for particular individuals, I incorporate additional techniques that are very useful in individual work. I will describe these approaches in the case study below.

Case study Referral and assessment I received this referral from the Centre for Deaf People because of the reputation I had acquired for doing anger management work. The referral was initially for two deaf clients, but only one of them attended the initial assessment session. I had been told that Mark communicated through lip-reading and sign language, so I organised a BSL interpreter for the assessment session. Mark was accompanied by his social worker. I arranged for Mark to sit with his back to the window, so that he had the best view, and opposite the interpreter, with me next to the interpreter (diagonally across from Mark), so that he could see both of us, but especially the interpreter. The room was a bit dark, so we put the light on. I checked with the interpreter to make sure I was speaking at the right speed within a comfortable amount of time. I also checked with Mark to see whether it was working for him. Occasionally, the interpreter stopped me because there was no direct equivalent in BSL to what I was saying and it took a little time to find the closest approximation. Mark was very good at stopping both of us if there was anything he

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did not understand. The interpreter was excellent, and she and I developed a good rapport so that the communication flowed well. Mark was 37 and had experienced a number of recent setbacks. He had been unable to complete a residential carpentry course because he had difficulty with the theoretical aspects and needed more time. Unfortunately, no further funding was available. In addition, he was very upset about his relationship with his girlfriend, which had just finished. He had had several rows with her, walking out in anger a few times. One of the causes of these arguments, according to Mark, was his suspicion that his girlfriend might be unfaithful to him. At times he felt quite paranoid about this possibility. He sometimes found himself in a blind rage and had to walk long distances to calm himself down. He was also worried and tense about things in general. He felt his head was ‘buzzing with overload’ and he was unable to relax. Mark had a son from a previous relationship, but there were disagreements concerning access. He had self-harmed in the past, by punching walls (Figure 11.1) and by drinking alcohol, but was managing to refrain from this behaviour while receiving support from the community psychiatric nurse at the Centre for Deaf People. He had also had thoughts of suicide, but kept these under control by thinking of his son. During the first assessment session, after some discussion with Mark, he said he would like to attend a few sessions with me, preferably using the same BSL interpreter. Fortunately, we were able to make this arrangement. He also decided that weekly sessions might be too intense, so we arranged fortnightly sessions with the agreement that he would continue to see his community psychiatric nurse between our sessions. They had been doing CBT together, which Mark had found helpful. We then arranged eight sessions to work on anger issues.

Session 1 The first half of the first session was taken up with planning, explaining how the sessions might go, looking at possible themes, setting dates and generally getting used to each other. I then encouraged Mark to choose some art materials and introduce himself on paper. Although a full range of art materials was available, Mark said he did not like messy things like paint and clay, preferring to use oil pastels, felt-tip pens and markers. I gave him a large sheet of white cartridge paper and he chose oil pastels. I wondered if he might find it embarrassing to have two people watching him while he drew,

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but this did not seem to be too great a problem. He did, however, find it hard to get things down on paper, but by the end of the session the paper was quite full (see Figure 11.1). Mark started by drawing three girls’ heads (top right), representing girlfriends who had betrayed him. One of them is holding hands with Mark. He drew himself on the left side of the paper, in green with a red ‘plus’ sign, which symbolises ‘honesty’ in BSL. He then drew a big knife in the middle of the paper. He said this was about an incident in which a previous girlfriend had attacked him with a knife. The brick wall with a fist (bottom left) represented the fact that Mark said he quite often punched walls, damaging himself considerably in the process. He next drew a little picture of a woman shouting and himself sitting sadly on his own. On the bottom-right side of the paper was his house. When he had finished drawing, I asked him how he was feeling. He said, ‘Crap’ and looked very tense. I asked him whether he knew ways to help himself feel good. He replied that he liked walking and had been working with his community psychiatric nurse on writing down good things about himself. He also said he felt angry in his body. I suggested a relaxation exercise for the next session and he thought this was a good idea.

Figure 11.1 Introductory picture.

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Session 2 Mark arrived in a tense and confused state. We started the session by looking at the physical symptoms he was feeling in his body that were related to anger. I drew a flabby-looking outline of a body on a large sheet of white cartridge paper, using a light blue marker, and Mark filled in the places where he felt affected, using an orange marker. He depicted clenched fists, tension in his chest, tension in his shoulders (the arrows) and confused thoughts in his head. He then drew a balloon coming out of his mouth to show that he was telling other people he was really angry (Figure 11.2).

Figure 11.2 Physical symptoms of anger.

Mark and I then moved on to the relaxation exercise. I discussed with both Mark and the BSL interpreter how we should do it. I usually ask people to close their eyes and then talk them through a relaxation, but clearly we needed to do this with Mark being able to see the signing. Surprisingly, it worked quite well. I asked Mark to relax each part of his body in turn, starting from his feet and moving up to his head. I allowed extra time because he needed to see the signing, register what was being said, and then do the action (or inaction). As part of the relaxation technique I included

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some breathing exercises. I asked Mark first to breathe deeply and then to find a steady rhythm whilst breathing in and out calmly. I then asked him to imagine a peaceful place where he could relax and feel at ease. He did not close his eyes but looked up at an angle while visualising. I then asked him to draw what he had visualised (Figure 11.3).

Figure 11.3 A peaceful place.

Mark told me he was sitting in some long grass, looking at a field of golden corn and watching the birds in the sky (he used a green marker for the lower section, a yellow marker for the upper section and a black marker for the two birds). No one was around and he was feeling at peace. We spent some time trying to work out how Mark could fit this image into his life, trying to replace some of the negative thoughts in his head with peaceful scenes like the one he had just visualised. I encouraged him to try it out during the week.

Session 3 Mark had not been able to do the relaxation, but had found the breathing technique very useful and calming. I asked him what he wanted to work on during this session, and he said, ‘So many things!’ – especially blowing up

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when someone was arguing with him. This suggested to me an exercise called ‘What’s underneath the anger?’ (Fine and Macbeth 1992). Because Mark was very tense, we started again with a relaxation exercise. I then asked him to think about a situation where he had become angry and had blown up. The exercise asked him to identify first the anger, then the hurt lying underneath the anger, then the unmet needs beneath that and, finally, the fears underlying them all. The example that Mark chose concerned his previous girlfriends. He had suspected all of them of being unfaithful to him and feared he may have driven them away through his anger. I wrote down Mark’s exact words with coloured marker pens on large sheets of white cartridge paper. As his English was not very good, he appreciated seeing the words in large coloured writing – despite the exercise being a verbal one, the art materials proved very useful: ANGER: Blowing up. Affair. Suspicious. When I found out. Angry with ex-girlfriends. Grabbed her (never done this before). HURT: Could not understand her. Sensitive person. Feeling let down, still loved her. NEED: Need relationship I can trust. Honesty in a person. FEAR: Of doing things wrong. Fear of losing her.

We then did a second example about a friend who kept bothering Mark, where his fear was that ‘I might whack him’. Mark began to see that, by looking at his hurt and unmet needs, he could meet those needs in some other way without blowing up. He might still be angry but he could keep in control, and also get his needs met. Mark declined the handouts I had offered at the beginning, but he was very positive about my offer to get the work he had done typed up, so that he could have a copy to remind himself. I wrote down the titles of handouts as extra topics he could choose.

Session 4 Mark and I looked at the list of possibilities and discussed which one might be the most appropriate to move on to next. He chose ‘positive and negative self-talk’ (one of the handout titles). I described this as a way to counteract the negative thoughts going round in our heads when things go wrong. We used a large piece of paper and coloured markers, as before, listing Mark’s negative thoughts on the left side in red (a colour he said he disliked). Then I asked Mark to find a positive statement to go with each of the negative

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statements. I wrote these in green, a colour Mark chose because he liked it. It was hard going, but worthwhile, because he could see the point of it by the end – it was a way to counteract the negative thoughts going round in his head when things went wrong. For instance, he replaced ‘I’m stupid’ with ‘I’m not stupid, I just made a mistake, I’ll take more care next time’. I asked Mark if there was one positive thought from this exercise that was particularly important or relevant to him. He chose, ‘I should talk about how I feel and not bottle things up.’ Again, I offered to get his work typed up for him for the next session.

Session 5 We looked at the notes typed up from the previous session and revised them briefly. Mark then chose ‘exploring early family patterns’ to work on during the session. He talked about how he felt isolated with his family members, all of whom were able to hear. Mark had attended an 11–18 comprehensive school with a Partially Hearing Unit attached to it, where the pupils had been encouraged to lip-read and speak, but were not encouraged to sign. He had only learnt to sign at the age of 19 or 20, when he became increasingly aware of being ‘different’, and a friend had taken him to Deaf Club. He said it was a great relief to be able to communicate with others and make friends in the ‘deaf world’. He could now travel to anywhere in the UK and be sure of a ready-made community of friends. I asked Mark to draw a picture illustrating when he first remembered getting angry. He used a large white piece of paper and a black marker pen. He drew a picture of stick figures (Figure 11.4). Mark placed himself on the left side of the picture, on his own, with a glum expression on his face. His first version of the rest of his family was shown by the line of figures at the top. When I asked what they were doing, he said, ‘Talking to each other and ignoring me.’ He then drew another three figures below facing each other, talking together and taking no notice of him. He described how he remembered first becoming angry about the situation at the age of about 16, when he felt his family did not like him. He later realised that this was not true, and that it was a result of communication difficulties. I wondered if this might explain Mark’s current ‘paranoid’ feelings which he had talked about. He had related going into a pub, seeing all his friends gathered together and thinking, ‘They don’t like me.’ I asked Mark if he thought this could be his 16-year-old self speaking, based on his experiences with his family. This seemed to make sense to Mark and light dawned

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on his face. He used the previous session’s learning to frame a positive message to counteract the negative one in his head: ‘They do like me – ignore the 16-year-old stuff.’

Figure 11.4 Family patterns: isolation.

Session 6 Session 6 was a review session with myself, Mark, his community psychiatric nurse and, the BSL interpreter. We went through all the issues Mark had worked on. He seemed much more confident and was using many of the techniques he had learnt, such as breathing, analysing his anger, hurt, needs and fears, and positive self-talk. He looked relaxed and happy, spontaneously saying, ‘I love myself a lot more now.’ We then planned the remaining four sessions: 7.

I-messages.

8.

Metaphors of anger.

9.

Bringing it all together or summary.

10. Final review with the community psychiatric nurse.

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Session 7 I explained the ‘formula’ for I-messages, as a way of expressing how we feel without being aggressive to other people. Their purpose is to let another person know what the problem is, what your feelings are and what you want to happen. The statements concentrate on behaviour that can be changed. Then Mark suggested examples of situations where he had become angry and upset, or walked off in a huff, and we worked on them, again using coloured markers on large sheets of paper, which I then typed up. It took a while for him to get the idea, but once he did, he could see that it was a way for him to avoid angry and destructive confrontations, at the same time sorting out problems positively. For example, instead of shouting, ‘Don’t stick your nose in!’, he worked out the following: ‘When I found out what you did, I felt angry because it felt like an interference in my affairs. Thank you for your help, but next time please don’t get involved. I would like to sort it out by myself.’ At the end of the session Mark said he had felt quite upset after the previous session, at the thought of all the ‘aggro’ he could have avoided in the last few years, if he had known then what he knew now. During the two weeks after the seventh session, Mark obtained a job on the same carpentry course where he had been before. The eighth session, therefore, would have been his last. Unfortunately, I had a cycling accident that day, ending up in hospital, and therefore was unable to round things off with Mark. He was disappointed not to be able to see me to say goodbye (as I was too). He told his community psychiatric nurse that he was grateful for the work he and I had done together and his ‘new way of being’. His community psychiatric nurse visited him two months later and found that he had been acting as an informal adviser and mediator to others with all sorts of problems, passing on his skills. Mark was planning a visit back to Bristol a month later and wanted to meet up with me to achieve a proper ending. We arranged a final session.

Final session Mark was accompanied by his community psychiatric nurse, who did the BSL signing for us. His job was still going well. I gave him the typed notes from our session three months previously, and we made a list of all the sessions and the topics covered. He talked about his ‘new way of being’ by saying: ‘I can explain myself now, I’m not so frustrated. I have self-respect. I

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can help other people – they come to me now. I enjoy going to the pub and meeting people.’ Mark filled in the Arts Therapies Service evaluation form, circling choices giving a score of 10 out of a possible 11 points. He wrote the following comments, with the help of his community psychiatric nurse: ·

A. Helpfulness of therapy: ‘I can now recognise negative thoughts. It helped me talk to my son and get a better relationship.’

·

B. Importance of art: ‘Drawing helped me and the questions/talk helped me get things out of my head on to the paper.’

·

C. Awareness of any change: Mark circled ‘a great deal’ and wrote, ‘If friends or family have a go, I know how to control things – no need to get angry. If anything bothers me, I go off and think about it, then come back and it’s OK. Other people come and talk to me now, they tell me I’m good at listening to them.’

Mark and I shook hands and said goodbye. He did not want to take his pictures with him, because he had nowhere to store them. He asked me to send him photos if I took some and I promised to do so.

Conclusion Although art therapy was only part of the work with Mark, it had a very pivotal role. In particular, the picture of his family seemed to be the catalyst for a very important insight concerning his patterns of behaviour. And by looking underneath his anger and frustration to the hurts he had suffered, he was able to learn to express these before he got to the stage of ‘blowing up’. In addition to the four pictures that Mark drew, the fact that the sessions took place in an art therapy room meant that art materials were to hand all the time. The use of large paper and coloured markers made a big difference to Mark for the CBT exercises, because he relied almost completely on his visual sense. This piece of work demonstrates that it is possible to work on anger issues using a mixture of art therapy themes and cognitive behavioural techniques. It also shows that it is possible to do such work with deaf people working through a BSL interpreter. The main factor that made it all possible, of course, was Mark’s motivation and willingness to really give it a try.

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References Bristol Centre for Deaf People (2005) Personal communication. Fine, N. and Macbeth, F. (1992) Playing with Fire: Training for the Creative Use of Conflict. Leicester: Youth Work Press. Higgins, L. and Huet, V. (2000) ‘Psychodynamic therapies, part 2: arts therapies.’ In P. Hindley and N. Kitson Mental Health and Deafness. London: Whurr Publishers. Hoggard, M. (2006) ‘Art psychotherapy with people who are deaf or hearing impaired.’ International Journal of Art Therapy: Inscape 11, 2–12. Huet, V. (1993) ‘Art therapy with deaf people.’ Inscape: The Journal of the British Association of Art Therapists Summer, 10–16. Ladd, P. (2003) Understanding Deaf Culture: In Search of Deafhood. Clevedon: Multilingual Matters. Liebmann, M. (2004) Art Therapy for Groups, second edition. London: Brunner–Routledge. Liebmann, M. (2007) ‘Anger management group art therapy for clients in the mental health system’. In F. Kaplan (ed.) Art Therapy and Social Action. London: Jessica Kingsley Publishers. Novaco, R. W., Ramm, M. and Black, L. (2000) ‘Anger treatment with offenders.’ In C. Hollin (ed.) Handbook of Offender Assessment and Treatment. Chichester: John Wiley & Sons. O’Rourke, S. (2000) ‘Behavioural and cognitive approaches.’ In P. Hindley and N. Kitson Mental Health and Deafness. London: Whurr Publishers. Turner, J., Klein, H. and Kitson, N. (2000) ‘Interpreters in mental health settings.’ In P. Hindley and N. Kitson Mental Health and Deafness. London: Whurr Publishers.

Part IV

Other Client Groups

Chapter 12

Angry Mothers Susan Hogan

Art therapy support groups Via the maternity liaison unit of a local hospital, and with assistance from the local group of the National Childbirth Trust, UK, I have conducted art therapy groups with a mixture of pregnant women and new mothers. These groups have been run with the aim of giving women extra support and the opportunity to explore their disrupted, fractured or dislocated sense of self-identity in pictures as well as words. The groups have had a celebratory dimension, as well as giving participants an opportunity to address more distressing aspects of the birth experience and the strains of new motherhood. I have become interested in the way that the multiple losses associated with childbirth can provoke anger. Other angry responses – to contradictory advice, to dealing with meddling relatives or to feeling violated after a traumatic birth experience – are perhaps more immediately obvious as potential sources of bewilderment, frustration and anger. Guilt is also a potential source of anger: many women feel guilty for leaving their babies, even though there is solid research which supports the fact that leaving new infants has no detrimental effects, so long as there is a fundamental consistency of care. This consistency of care may include many different carers (Blaffer Hrdy 1999, p.500). It has become a popular myth that leaving your baby, even for a few hours, can cause it psychological damage, when this is simply not supported by research findings. There are few routinely available support services for new mothers, despite cogent longitudinal research findings which show the manifest long-term benefits to both mother and child of such provision (Oakley 1992; Oakley, Hickey and Rajan 1996). This chapter will explore the issues and concerns which have been to the fore in the art therapy groups. It is based on transcripts of the groups.

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Becoming a mother Some women are immediately aware of a sense of loss, but for others this is a feeling that creeps up on them more slowly, through a succession of little incidents: it is a slower realisation that their old self is irretrievably gone, a more incremental revelation, and it is this which I wish to highlight here. Of course, we are talking about psychic death and rebirth; it is not simply a question of loss, but there is sufficient analogy to warrant a brief reference to the literature on bereavement. Bereavement is not simply about the absence of a person, it involves the pain of relinquishing ‘old roles, patterns of interaction, and sources of gratification…’ (Raphael 1984, p.57). As Kübler-Ross (1970) and others point out, anger is a very common reaction to loss; it is interspersed with other emotions and denial, but resurfaces at intervals. She suggests that the anger may be ‘displaced in all directions and projected into the environment at times almost at random’ (p.44). Furthermore, it has been suggested that ‘inhibited grief ’ (in this case the lack of acknowledgement of women of their inevitable losses) is particularly likely to produce anger and ‘intense and furious rage’ (Raphael 1984, p.60) or, alternatively, incomprehensible depression. To a certain extent, this accounts for the profoundly angry images sometimes made in art therapy, or imagined in day dreams, which often seem almost inexplicable to those who do not feel consciously angry, or who have great difficulty in articulating angry feelings (and anger, let’s face it, is not maternal: it is positively iconoclastic in relation to what should be a period of serene bonding, as prominent ideology would have it). Some women rush back to work, and then, quickly or slowly, often realise they are finding it hard to cope. They also discover that even female colleagues are somewhat less sympathetic than they might have hoped. Indeed, the discriminatory way many women are treated on their return to work (with illegal changes of remit, inferior office provision and less career development) can come as quite a shock. Often, employers will not make allowances for motherhood, despite European Community (EC) directives, and expect new mothers to conform to corporate norms, for example, the inevitable presumption of unpaid overtime. Or women are suddenly regarded as ‘unreliable’ on their return from maternity leave, even if they conform to the corporate cultural norms rather than challenging them. Many employers give short shrift to the idea that further compromise is necessary or desirable, following the disruption caused by women having audaciously

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taken maternity leave. The idea that a period of ‘light duties’ might even be appropriate in some cases does not seem to enter into the debate. That some women should end up feeling angry is entirely rational.

A bad birth But what about the physical shock of having a baby which makes so many women feel angry? This should not be overlooked. One of my former art therapy clients, Jay, described her birth contractions as, ‘an extraordinary experience…it’s like things moving through you – it’s a force that is so uncontrollable – I was revelling in it’ (Hogan 1997, p.241). Of her emergency episiotomy, she went on to say it felt like a ‘mutilation’ and a ‘kind of rape…’ and that she felt ‘betrayed’ by her partner who had not defended her against this unwanted intervention (Hogan 1997, pp.242, 266). Clearly, a woman’s expectations, as well as cultural norms, are at play here.

Figure 12.1 Jay described her episiotomy as a ‘kind of rape’.

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My client, Jay, above, felt ‘betrayed’ as she had wanted a ‘natural birth’ at home and ended up in a hospital setting where she felt she was treated with profound insensitivity. But more than that, in her eyes, her husband had failed to protect her. In the UK, many women, often with their partner’s full involvement, make ‘birth plans’ which list in detail what interventions they are willing to consider and in what circumstances; these are then discussed with midwifery staff who are given a copy. But the reality is that hospital rules often take over; even midwives in the home are constrained by hospital protocols. Women’s expectations of maintaining control over their own bodies and an important symbolic event, perhaps the defining one of their lives, are frequently bulldozed. The incredible anger women feel after having had a bad birth is not always mitigated by the presence of a healthy child. Some women are simply too exhausted or traumatised to be able to enjoy their newborn infant. The pain of perineal tearing, episiotomy or Caesarean section is very real. The mind-blowing fatigue of those giving two-hourly feeds all night is very difficult to imagine for those who have not endured it. The exhaustion is cumulative and may lead to immune deficiency, allowing infections, which then add to the exhaustion, making the early months of motherhood intensely demanding. Kitzinger (2001, p.189) suggests that unwanted medical interventions result in some new mothers being ‘left to cope with feelings that are very similar to those a woman experiences after being raped, and which often persist weeks, months, and even years later’. The actual physical trauma and shock of childbirth should not be underestimated. A group participant (Sandra) described her unexpected feelings of terror: ‘Physiological changes can be very powerful. I was – four days after the birth, I just lost it completely, you know. I was freezing – couldn’t get warm, shaking: [my] whole body shaking. I’m sure it was a kind of shock…’. And Sandra was utterly alone as she experienced this, except for her baby, her partner having already returned to work. The endocrine changes after childbirth have been described as ‘unmatched’ by any other biological event. Indeed, the body’s craving for steroid hormones, such as cortisol, oestrogen and progesterone have been likened to the withdrawal effects experienced in giving up alcohol or heroin (Hogan 2006, p.120). This, combined with possible disappointment, or a tangible sense of having been violated, being in a state of shock, pain, discomfort or disorientation, is what is often rather condescendingly referred to

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as ‘baby blues’. I think ‘post-birth trauma’ describes it rather better. Whilst some women may breeze through this, it is not realistic to assume that every woman should, and to ‘pathologise’ those who do not. More positively, women having a second or third child are likely to make different choices in reaction to earlier bad birth experiences. Nora Swan-Foster (1989) notes that women can use art therapy during pregnancy to address emotional issues concerning a bad first birth. She gives the example of Jenny, who wanted a vaginal birth after a Caesarean section. Her bad first experience stimulated intense emotions during her second pregnancy, including ‘feelings of anger, fear, grief and helplessness’, which she was able to explore in art therapy (Swan-Foster 1989, p.289). Women are able to reflect in the art therapy group on how they want their next birth to be and actually make images about it; they can imagine it in a very tangible way. Consequently, the art therapy support groups are very useful for women having a second or third child, as well as for new mothers.

Power and control, and doing it ‘naturally’ A number of subjects arose quite strongly in the art therapy groups. A dominant and recurring subject was that of autonomy and the feeling of being manipulated (physically and psychologically). This was linked to perceived coercive threats by professionals with the power to impose unwanted interventions or actually remove the baby. This had an inhibiting effect on the women’s openness to the professionals whom they dealt with, and all the women in the groups were aware of this to some degree. Linked to feelings around control were feelings towards the baby which were not expressed; these included emotional disengagement or violent impulses, which could be pictured or described in the safety of a confidential art therapy group. One woman said: I can understand how people can be aggressive towards their children, because you’ve got all these feelings and they don’t come out… (Lyn)

The desire to acknowledge feelings of despair or self-doubt was made harder by discourses about ‘maternal insight’ or the ‘naturalness’ of the mothering role. Guilt featured quite strongly: I didn’t have this instinctive deep love for my baby. She didn’t feel like my baby…because I didn’t feel this bond…it made me doubt so many things about whether I was right to have it. (Elsie)

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Art therapy enabled women to picture themselves doing things differently or to depict their fears: to envisage how they saw something going – or dreaded it going. Elsie’s lack of maternal confidence stopped her taking her baby to the supermarket where she imagined her baby crying uncontrollably and herself becoming the centre of attention: I had no confidence about being able to stop her from crying…I just thought, what if I’m out and she cries and I just can’t shut her up and then everybody’s going to be looking at me…I wouldn’t have coped with that and I would have just fallen and burst into tears and probably just sat on the floor and just wailed…I had this real fear of strangers. (Elsie) You’re a normal person yet the next minute you’re supposed to have intimate knowledge of everything the baby needs…[When] she started crying, Beth said to me ‘What does she want?’ I said, ‘Well, I don’t bloody know actually. What do you think?’ (Denise)

All of the women were aware of an unprecedented amount of interference in their lives, either from relatives or the medical professions, or both. Interwoven with ideas about women’s natural propensities were discourses about what is ‘appropriate’ and ‘normal’. Women in the groups acknowledged that they experienced fear or inhibition about expressing themselves in a number of ways, because of how they might be perceived or judged by the professionals whom they dealt with: obstetricians, parent craft instructors, health visitors, midwives, GPs and so on. This had both subtle and obvious consequences and effects. Lyn, for example, was looking forwards to being a mother but anxious about going into hospital: I don’t like hospitals, and again it’s this control-freak thing – it was just like – I just felt really like they wanted to make me into a medical condition and wanted to control me.

Later, after the birth, Lyn was frightened to admit how terrible she felt, ‘’Cos you’re kind of worried that they’re going to take your baby away [because] you’re an unfit mother.’ Lyn also felt resistance to being ‘turned into a medical condition’. Her fear caused her to be very cautious when she was eventually interviewed by a psychiatrist. She told the psychiatrist what she thought he wanted to hear rather than how she really felt. Another group member, Elise, felt overwhelmed by the amount of contradictory advice she received from different professionals and others. Referring to what she had painted, she said:

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I’ve got a crowd of people saying – ‘you must’, ‘you need to’ and ‘don’t do this’ and ‘I did this’ and they’re going hammer, hammer, hammer at you all the time!

Also evident in Elsie’s description is her experience of a lot of guilt because she failed to conform to the ideals of maternity she had read about in books: I was very sick…so all the books that say you must eat so many portions of vegetables and meat and this, that, and the other, you know, I couldn’t do it…So I worried myself to death over this…And so your head starts then, when you first get pregnant…I think the guilt starts there right at the beginning, and possibly, yes, if it was an unplanned pregnancy as well, it probably starts the moment you find out, the moment you do that test, you know, and it sort of carries on through… (Elsie)

Of the actual birth Elsie said: The birth didn’t go to plan. It was early. My waters went, and that says to me your body says it’s ready for the baby to come, and it doesn’t come for 24 hours. You know, and you’re in and out of hospital. No, you can’t come in yet, you’re not dilated enough – but you’ve got to come in now, because we can’t let you go over time – and you think, you want me to come in, you don’t want me to come in? What do you want me to do? So you do feel – you know the medical thing – you do feel [it] very much. You’re being told, you’re being moved, you’re being looked at, and poked at, and everything else, and my baby came by Caesarean because she still wasn’t coming out.

Elsie did not get to hold that baby first – after the Caesarean it was handed to her husband. She said, ‘You feel really done. You feel cheated.’ Denise felt she gained a lot from simply being able to acknowledge that she didn’t like her baby very much. Suzi expressed fear of the hospital setting, referring to ‘horror stories’ and saying that she thought a home birth would be less traumatic. As well as a general dislike of hospitals, she was contemplating a home birth so that she would have more control: I’m worried about losing control and the midwife just taking over…I feel like my body’s been taken over in some respects.

Suzi also felt that she would be more comfortable at home. In part her fears were to do with her mother’s experience. She elaborated:

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Maybe if I have an OK birth, and if I feel in control of the birth, and I feel like I’ve got some more of a say, and it’s not all taken away from me, then I’ll deal more positively with the baby. Maybe that’s because of my mum. She went through, like, a 72-hour labour that was horrific, and I nearly died in the process…I know things are different now and that they wouldn’t let anyone go for that long.

Another member of a group expressed similar reservations about hospitals, except her concerns focused on abandonment: It’s quite, almost [a] conveyor-belt type [experience]…you know it’s that. I think in comparison when you’re at home you’ve got people there with you, they’re not gonna rush off anywhere. (Anne)

The pregnant women in the groups were aware of pressures constraining their behaviour. One woman was upset when her partner no longer felt that a pierced belly button was ‘appropriate’. In her general dealings with the medical professions, she said she felt ‘pushed and pulled in every direction…I feel like my body’s been taken away from me. You know, being told what to do all the time…I don’t feel in control.’ When positive advice was given, her midwife stressed that worrying could harm the baby: ‘If you don’t ask you’ll be going on worried and it’s not good for the baby’, the midwife had said. Although the intervention was intended to be helpful, it added another layer of anxiety.

Exhaustion and dismal aspects of motherhood Our sense of self-identity is bound up with what we are capable of conceptualising and remembering, so it is not surprising that extreme fatigue, which disrupts these faculties, proved challenging and destabilising. The effects of exhaustion were a recurrent theme throughout the sessions. Some of the women felt tired because they were heavily pregnant, some because they were feeling and being sick, and others because their babies kept them awake. The disorientating effects of severe sleep deprivation were described by one participant who said: I had ever so vivid dreams. I started mixing up reality and the dreams. I said to a friend ‘I took the advice you gave me about breast feeding and it was great,’ and she said ‘I didn’t give you any advice.’ I’d dreamt that she’d given me advice! That incident made me think, I’m losing it! I’m

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really losing it! I’m mixing up reality with my very vivid dream-life. (Sandra)

Another woman said, pointing at a mask she had painted: That was my mask…you say yes, I’m doing fine. The baby is doing fine and no, I’m not worried about anything and yes, I’ve got ten pairs of clean knickers and this and that and the other. But behind it you’re thinking for God’s sake leave me alone. Sometimes I found I wanted to feel depressed and alone and go with it rather than fight it because it was too much effort to act… (Elsie)

Elsie also talked about the difficulty of getting her baby to sleep when other people in the hospital seemed to manage with ease, and how this affected her self-confidence: So I’d been trying to get Kezia to sleep at night – to quieten down around about 9.30 and Kezia’s still bawling and bawling…and I tried not to ring for the nurse because I didn’t want to be a bother – instead of saying I need help – so I left it until I was there basically and they would just take her off me and she would be asleep before they got through her curtain and I would think – you sod – I’ve been there for two hours – rocking – what can you do? So you feel like you don’t know how to deal with your own baby.

Another group member said: …my brain at the moment feels like a complete void. It’s just, like, up till now I’m so used to being busy, working, doing stuff. I’ve read so many books I can’t even – I’m beginning to mix up characters in books and stuff. I’m reading back over pages thinking, Oh God, I can’t remember what’s happened in this book! (Denise)

All the women were experiencing profound changes. These were different for the two groups of women involved. The pregnant women were concerned with bodily changes, changing roles and relationships, preparations for the impending birth (including dealing with the fear of death). The women who had already given birth were more concerned with their feelings towards their children, and adjusting to a new life. This adjustment was hard as their new lives were not what they had anticipated. It is one thing to know intellectually, for example, that infants cry but quite another to be in the actual situation of trudging up and down at four o’clock in the

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morning with a screaming baby. Aspects of tedium and repetition were acknowledged by group members. Sandra said of her baby’s night waking: Mine had colic and I had walking up and down sessions with a screaming baby for like months – screaming baby – walking up and down, and it wasn’t fun; there is no way that you could say that it’s fun.

On another occasion a debate about post-natal depression arose. Sandra felt uncomfortable about the term: I don’t know on a theoretical level how they’re defining post-natal depression…I mean they’re pathologising a response which might be in some ways utterly reasonable you know, if you’ve been in the equivalent to being involved in a car accident…I really did feel as though I was in shock.

Denise discovered that the reality of motherhood did not match her expectations of it: I really feel that I’ve been a bit steam-rollered ’cos of the whole pregnancy thing and going overdue and then having this enormous baby and then the Caesarean and the [blood] transfusion and being in hospital which was, you know, not a nice experience…then coming home with this thing that’s really lovely and cuddly and smells gorgeous but at the same time needs you so much, and it’s really strange, and coming to terms with all the feelings…you hear of people saying that as soon as they heard the baby [cry] there was this bonding rush of love…that had worried me…I know that I love her, but it’s just not gonna be the way I’d imagined it to be.

She also doubted whether she had made the right decision to have a baby at all: I’d imagined I was really going to be a wonderful mother because I wanted to have children and suddenly I’m thinking – God, I think I made a mistake…It goes against everything I ever thought about myself… (Denise)

Vulnerability and lack of support Another theme was that of relationships. Problems already existing between family members before the pregnancy tended to become exacerbated.

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Parents and in-laws, their expectations and interference, caused the women and new mothers some stress. Lack of support from husbands, or the feeling that the experience could not be fully shared or properly understood by spouses, caused women to feel alienated from or angry with their partners. Some women resented their husband’s ability to forget about the pregnancy, and had to deal with feelings of extreme rage.

Breast-feeding Throughout pregnancy and nursing, women are urged to relax, and mime the serenity of madonnas. (Rich 1976, p.36)

Breast-feeding was a considerable source of tension for some women. One woman had received a lecture about the benefits of breast-feeding from her mother-in-law when she was just a few weeks pregnant. Another woman felt under pressure to breast-feed, but was relieved by her decision to change to bottle-feeding. Elsie explained how impossible she found the experience of trying to breast-feed in hospital: I was trying to breast-feed. Kezia only fed for ten minutes at a time and [then] went to sleep. This is where my confidence went, in hospital, to be honest. Because they said, ‘Wake her up – she needs more.’ And I thought, you try and wake her up – she’s gone – you know. And they said, ‘How long does she sleep for?’ Well, maybe half an hour… ‘Oh well, try again then – don’t let her go too long if you can.’ [they told me]…You are supposed to swap over sides. ‘Well, do I swap over then?’ – ‘No, no, ten minutes isn’t enough, you’ve got to stay on the same side.’ So by the end of the feed, one [breast] was all right and the other was boom boom boom…and I thought – Oh my God! So you do what they say and then you get another nurse and they tell you something different and you think, which one should I listen to? I felt I was out of my depth on day one I did – totally… (Elsie)

As well as feeling bewildered and oppressed by the conflicting advice she was being given, Elsie also felt bad about not being able to adopt routine feeds, even though it is clear from the transcript fragments that she was responding to her baby’s demands: And my friend used to say, ‘You should make her go four hours’ [between feeds]. You can’t – the screaming and wailing – [you can’t say

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to the baby] ‘You’ve got to wait another two hours. You’re not having any more!’…They’d say, ‘I was strong with mine’, basically implying that I was weak – so my confidence was just going…

Denise also had a terrible experience of attempting to breast-feed in hospital. She also resented the fact that the women encouraging her to breast-feed did not do it themselves. Her anger is evident: They say if it hurts you’re not doing it right. A lot of the people who are advising you have never breast-fed themselves. They’ve learnt it through books, you know, like the health visitor. She was sort of helping me and she said, ‘Of course, I’ve never actually breast-fed at all.’ So you’re saying to me if it hurts you’re not doing it right but then you don’t have a ten-pound baby sucking on you for 40 minutes…I’m not finding it a building experience that everybody said it would be, not that I don’t, I do love her, obviously I do.

Denise also worried about how much milk her baby was getting: I think with breast-feeding as well it’s ’cause you don’t know how much they’ve had that I find difficult…is she still hungry?

Sandra noted how the midwives who ran the ante-natal class she attended introduced anxiety on the topic of breast-feeding when she had previously been feeling quite relaxed about the prospect: The midwives they all went on about problems with breastfeeding…and it [had] never occurred to me that it might be problematic. You just get the baby and give it a drink.

This was more irksome than enraging. Other more minor themes and issues arose in the groups. Although the women expressed fears about the possibility of having a mentally or physically handicapped baby, it emerged that several of them had declined to take blood and other tests designed to check for abnormalities. This decision had precipitated feelings of guilt and resulted in pressure to have the tests from healthcare professionals and others. Refusing such screening may be very difficult, especially when tests are presented as both routine and rational. There appeared to be a consensus among the women that they would have liked a designated midwife whom they could get to know well and who would attend their birth (this is possible in some parts of the UK). Several of the women complained about rota systems which resulted in their never

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knowing who they would be dealing with for ante-natal check-ups, or who would be in attendance at the birth. Two of the women who had had Caesarean sections bemoaned the lack of opportunity to rest after the operation. They were aware that women who have Caesarean sections are given less chance to rest than other operative cases. Another subject that arose was the idea of motherhood as a fresh start or a new beginning (and connected with this, for some group members, were feelings of ambivalence about past behaviour). In this context, women expressed positive feelings about pregnancy and being with their newborn babies, along with feelings of great excitement and elation. This included the expression of positive feelings about partners and husbands.

Conclusion In this chapter I have summarised the main issues which arose in the groups. It would be bad research to generalise about women’s experience from a relatively small amount of data. However, it is interesting to note that the two women who felt particularly depressed after their pregnancies (and regarded themselves as post-natally depressed) had both had Caesarean sections and neither had been the first to hold their baby after the birth. Both women had concerns about needing more ‘personal space’. Lack of ‘space’, or a feeling of having lost a sense of personal space, was a prominent theme, so the pictorial space provided by the use of art therapy was very relevant to the women. Themes of loss of self and personhood, or a disrupted sense of selfhood, translated into images. The pictorial space also afforded an opportunity for the reconstruction of a lost sense of self. This vital process of readjustment was aided by the art therapy. It is also interesting to observe that all of the women in the groups had some difficulty in relating to healthcare professionals. Art therapy afforded women an opportunity to express their anger and frustration about this. Women’s feelings that their bodily integrity was being undermined were justified, as hospital protocols overrode individual aspirations, resulting in some women feeling violated (Martin 1987). These are complex topics and it is hard to do justice to them in such a short piece of writing. However, I hope that this chapter will be of interest to those concerned with women’s issues in general, as well as art therapists thinking of working with this client group. Furthermore, I am ever hopeful that the medical profession will recognise the importance and long-term

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value of providing emotional support for women as part of standard ante-natal and post-natal care.

References Blaffer Hrdy, S. (1999) Mother Nature: A History of Mothers and Natural Selection. New York, NY: Pantheon Books. Hogan, S. (1997). ‘A tasty drop of dragon’s blood: self identity, sexuality and motherhood.’ In S. Hogan (ed.) Feminist Approaches to Art Therapy. London: Routledge. Hogan, S. (2006) Conception Diary: Thinking About Pregnancy and Motherhood. Sheffield: Eilish Press. Kitzinger, S. (2001) Birth Your Way: Choosing Birth at Home or in a Birth Centre. London: Dorling Kindersley. Kübler-Ross, E. (1970) On Death and Dying. London: Routledge. Martin, E. (1987) The Women in the Body: A Cultural Analysis of Reproduction. Milton Keynes: Open University Press. Oakley, A. (1992) Social Support and Motherhood. Oxford: Basil Blackwell. Oakley, A., Hickey, D. and Rajan, L. (1996) ‘Social support in pregnancy: does it have long term effects?’ Journal of Reproductive Psychology 14, 7–22. Raphael, B. (1984) The Anatomy of Bereavement: A Handbook for the Caring Professions. London: Hutchinson. Rich, A. (1976) Of Women Born: Motherhood as Experience and Institution. London: Virago. Swan-Foster, N. (1989) ‘Images of pregnant women: art therapy as a tool for transformation.’ The Arts in Psychotherapy 16, 283–292.

Further reading Hogan, S. (2008) ‘Postmodernist but not post-feminist! A feminist postmodernist approach to working with new mothers in current trends and new research.’ In H. Burt (ed.) Art Therapy: A Postmodernist Perspective. Waterloo, ON: Wilfred Laurier Press.

Chapter 13

Art Therapy and Anger after Brain Injury Sally Weston

Introduction The first time I worked with a client with brain injury, anger was an issue high on the agenda. Tom (all names have been changed to protect client confidentiality) was in a community-based art therapy group at a centre for unemployed people. He was in his early thirties and had previously worked in a professional job. The reason he sought the help of the group was that his life had come to a crisis point. Unemployed since his brain injury, and left with visible disabilities, he suffered jokes in the pub and taunts in the street. Finally, this taunting had become unbearable and he had lashed out and been arrested for assault. In the first session Tom drew a picture that he said was an image of the world as he saw it after he came round after his operation. It was an everyday object – a record on a turntable, doubled and distorted. It looked both surreal and like an optical illusion. I did not know what to make of it. After this first session, Tom did not deal overtly with the issues he came with – his anger and frustration after his brain injury – but went on to explore the qualities of the art materials and produced landscapes of peaceful lakes. When he left the group he said he felt a lot better. ‘Art therapy should be available in hospital,’ he said, as it would have helped him come to terms with what had happened earlier. The next time I worked with a person after brain injury was on an acute psychiatric ward. The client was a woman with severe speech and understanding difficulties, who had been sectioned into hospital after using threatening behaviour towards her family. This was thought to be a reaction to her communication difficulties. She came to several sessions of an open art 211

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therapy group before she was moved on. Like Tom, she made full use of the sessions, attending every group and eagerly using the materials, producing colourful, lucid, figurative images. Despite my ignorance about brain injury at the time, both people seemed to gain from art therapy. Using the art materials to express themselves, they were on equal terms with others in the groups. After his time in the group, Tom worked individually with an art therapy trainee, and, although it was over a year since his brain injury, he explored the ‘unfinished business’ of his traumatic experience in hospital. It is interesting to reflect in retrospect that both patients were in trouble because of expressions of aggression and anger, and this was the reason behind their referral to art therapy. I have now worked as an art therapist in a neuro-rehabilitation unit for a number of years and have a better understanding of anger and aggression after brain injury, which, though its means of expression may be exaggerated by neurological damage or cognitive difficulties, at its heart mostly seems to be an understandable reaction to devastating loss. More people are surviving moderate and serious brain injuries than ever before, but the consequences of brain injury are not well-understood by people who have not come into direct contact with it. I will begin with a brief background to the current situation.

Brain injury Recent increased survival rates are attributed to the considerable advances in surgical, paramedical and intensive care. Following medical recovery, survivors are generally expected to have a full life expectancy. However, serious brain injuries continue to have an effect which may be physical, cognitive, emotional, social or economic.

Causes of acquired brain injury The causes of acquired brain injury include road traffic accidents (a large proportion), assaults (including domestic violence), suicide attempts resulting in lack of oxygen to the brain, sports injuries, injuries caused by surgery, falls and accidents at work. These forms of externally caused head injury are called ‘traumatic brain injuries’. So-called ‘non-traumatic brain injuries’ (the ‘trauma’ refers to the physical cause of the damage not the subjective experience of the person with the injury) include aneurysms

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(bleeding within the brain), brain tumours, anoxic brain injuries (prolonged lack of oxygen to the brain) and infections such as encephalitis, meningitis or Guillain–Barré syndrome (an autoimmune syndrome that affects the neurological and muscular systems). Specialist rehabilitation is thought to lead to better outcomes. However, services are patchy and have not caught up with the better-funded acute brain services.

Neuro-rehabilitation services In the UK, neurological rehabilitation units evolved from the former young disabled units (YDUs). The increasing survival rates and distinct rehabilitation needs of severely brain-injured patients saw a gradual development of a specialist service, and, in 1994, government money was made available to set up a number of specialist units (Rose 1999). The service I work for is a hospital-based specialist unit that offers assessment and treatment for people with acquired non-progressive brain injury who are thought able to benefit from a period of ‘inpatient rehabilitation’. This is early rehabilitation. Someone with moderate or severe head injuries may be involved with further community-based rehabilitation services up to two or three years after injury. The accepted model of neuro-rehabilitation is a multidisciplinary one (Johnstone and Stonnington 2001). The British Society of Rehabilitative Medicine (BSRM) recommends that professions in rehabilitation units include physiotherapy, occupational therapy, psychology, nursing and the medical profession, speech and language therapy, and art and music therapy. Dieticians, dentists and psychiatrists are also called on when needed. There are regular meetings and reviews involving patients, relatives, significant friends and all the individual staff involved with each patient. This may seem cumbersome but recovery from brain injury is very complex. It involves body, brain, mind and the patient’s life before injury. Any of the specialist professions, family friends or patients themselves may have significant insights which need to be shared. Within the team the specialist role of the art therapist is to offer treatment for emotional and psychological needs. Before concentrating on issues of anger, I want to put it into context by giving a brief overview of the complex picture of loss and the attempt to adjust and recover which faces a person after a serious brain injury.

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Emotional and psychological issues after severe brain injury People often have a significant psychological reaction to brain injury. The BSRM states in its guidelines for rehabilitation after brain Injury (BSRM 2003, p.45) that ‘anxiety and depression and other disturbances are extremely common following brain injury and likely to increase over time if not treated’. Estimates are that, in general, approximately 60 per cent of patients suffer clinical depression in the years after their injury. Serious brain injury involves major adjustment and can include any or all of the following: ·

coming to terms with the physical damage of the brain injury: physical ability, communication, cognitive functions

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working through the effects of severe trauma

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the need to grieve losses

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the need to adjust to changes in relationships

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adjusting to a personal life that has been severely disrupted

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adapting to changes to roles in the world

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the need to find meaning to a life with brain injury.

Most of the above could apply to other severe traumatic injuries or sudden disabilities. There is, however, an additional and, arguably, the most devastating issue facing people with brain injury. Memory, learning skills, the ability to think or organise thoughts, emotional reactions, social interactions, communication and understanding can all be affected. This means that the ways that each person has developed over their lifetime to cope with trauma or change, to plan and live life, can no longer be relied upon in the same way as before.

Emotional needs in early rehabilitation Severe brain injury cannot be separated from social context. At the point of admission to the rehabilitation unit, it is often relatives and other close friends who are traumatised. The brain-injured person will almost certainly have been close to death, and the circumstances may have involved negligence or assault from others. However, the brain-injured person will have no memory of this and will never recover the memory of the actual incident or of a varying amount of time beforehand.

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Initially, people may be grateful to be alive; they are assimilating what has happened to them and what they are being told about the periods during which they have been unconscious. However, as patients recover physically, psychological and emotional issues tend to come to the fore. At a point where the patient’s recovery is the most dramatic, they are often far from the mood of celebration that staff and relatives are generally feeling at their progress. Instead, they are often then taking the journey their relatives took while they were unconscious – shock, disbelief and grief. The art therapist has a particular role in working with this dynamic.

The role of the arts therapies The arts therapies are an accessible form of help for people facing the complex emotional, neurological and cognitive difficulties that follow severe brain injury. In the past 15 years since art and music therapies began to be incorporated in neuro-rehabilitative units in the UK there has been increasing discussion about the importance of addressing emotional and psychological issues. George Prigatano, a psychotherapist and psychologist who has worked in the field for many years, argues that the issues of trauma and loss need a psychodynamic approach to complement the cognitive and behavioural therapeutic approaches found in rehabilitation. However, people who have problems with reasoning, language and memory, cannot generally access verbal psychotherapies. Prigatano and art therapists alike have argued that the arts offer alternative means of expression and communication, so using the arts within a therapy relationship can enable brain-injured people to access much-needed psychotherapeutic help (Garner 1996; Prigatano 1991). There are a small number of art therapists who have written about their work with brain-injured clients. Wald (1989) and McGraw (1989) both wrote articles about their work in the USA. Both pointed out that, even at early stages of recovery, people may benefit greatly from engaging with art materials – their sensory qualities can access feeling and trigger memory, and engage many parts of the brain. As insight increases, the therapeutic relationship can develop and people can address issues of loss, grief and anger. In the UK, an article published by an art therapist described work in a rehabilitation unit (Wisdom 1991).

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Anger after brain injury: neurological and cognitive issues Anger is one of many inter-related issues to be faced after brain injury. Not every one is affected in this way; in fact, a more common neurological problem is an absence of expression of feeling, or ‘placidity’ (Sury and Sano 1999, p.16). However, rage and aggression may be produced by brain lesions, but because of its social expression it is more likely to be regarded as a problem that needs treating or modifying (Rose 1999, p.27). Anger is an area that is often misunderstood by friends and relatives. Because people may well appear ‘normal’, outbursts of anger and irritation may seem unreasonable because they are unpredictable, or frightening because they are excessive or simply ‘out of character’. Brain-injured people may be labelled ‘narcissistic’ by professionals or ‘selfish’ by friends. Damage to the front of the brain (a common injury site) often seems to lead to angry outbursts. The reason for this is thought to be that the frontal lobes are important for abstract thought, planning, controlling emotion and self-restraint. Loss of or alterations to these restraints mean that some brain-injured people find themselves reacting to their feelings rapidly and without the usual adult inhibitions. Loss of the ability to think abstractly, such as seeing oneself accurately, interpreting situations or understanding social context, may also create problems (Laatsch 1999). Cognitively based anger management programmes developed for brain-injured people cover both the external manifestations, such as shouting or violence, and the internal feelings – described by one participant as a feeling of overload in the brain, ‘like a grid-locked traffic jam’. As well as work on self-regulation, attention is paid to rebuilding lost basic social skills. The principle around such programmes is that whilst damaged brain tissue cannot be repaired, new strategies can be developed around neurological and cognitive limitations. These can enable people to understand and control their anger. An art therapy approach that is art-based and psychodynamic is less directive and allows the client to explore issues at the level they wish and in the context of their other problems. Anger, like other emotions, is seen as a part of a bigger picture, which may need to be explored. Art-making enables patients to explore simultaneously emotional, cognitive and neurological issues (Garner 1996). I would now like to write about a particular client who used art therapy when anger was the focus of his difficulties and an issue in his life. He was

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one of the first clients I worked with over a long period of time (12 months in all), and the therapy spanned his time as an inpatient and a period on his return home. I contacted him in connection with writing this chapter, seven years after the treatment. I had remembered his art work and felt it communicated well the issues he was facing – issues that seemed to need a non-verbal means of expression. He was happy for his work to be used and hoped (as I do with this chapter) that it would help people understand the difficult experiences resulting from severe brain injury.

Case history Nathan was a young man of 17, who had been assaulted on the sports field and received a serious brain injury. He made a good physical recovery and probably for that reason was discharged home straight from the acute wards, without a referral to the rehabilitation services. Once home he seemed a changed person – uncharacteristically irritable and angry towards his younger brothers. His concerned mother contacted their general practitioner (GP) and Nathan was referred for a multidisciplinary neurological assessment.

Figure 13.1 ‘Oh my God! They killed Kenny!’

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When I first met Nathan, he was relieved to be back in hospital where he might gain some understanding of what was happening to him. I told him about art therapy, explaining that he could use the sessions to explore what had happened to him and how he was feeling. In the first session Nathan told me he had a problem with anger and was distressed that he was focusing this on his family. He felt bad about this. He responded positively to ‘doing some art’, telling me he was not very good, but he liked graffiti. He had a lot of books, pictures and computer games in the ‘bed space’ in a ward he shared with three other men. He took a postcard down from his wall and copied it in his first art therapy session. At this time South Park was still something of a cult cartoon television programme, but the subject also resonated with his situation. In the image Nathan drew (Figure 13.1), Kenny (the little brother) is lying on the floor on the left with his head half torn off. The words ‘Oh my God! They killed Kenny!’ appear above him. A regular feature of the South Park storyline is that in the next episode Kenny will be walking about as if nothing had happened. To me this image and the story behind it seems a very useful, even archetypal, image of the experience of waking up seriously injured with no personal memory of what has happened. There is another written phrase, at the bottom right of the picture: ‘Kick Ass!!’ This could be read as part of South Park’s general defiant ‘tough’ humour, but the point is surely about a desire to fight back. At the time I made no comment on the resonance I saw in the image with Nathan’s own situation. Drawing seemed to help him relax and talk. This seemed the most important thing in the early sessions. Whilst an inpatient on the ward, Nathan attended art therapy regularly and drew pictures using graffiti and cartoon conventions, and characters from films and computer games. I enjoyed his pictures and felt I was getting a privileged access to contemporary male teenage culture. He seemed to be using the sessions well to help him work out what was happening to him and adjust to the consequences. He would draw for most of the session and, beneath the camouflage of the brim of his baseball cap, he was talking to me. He told me about his family and what he was beginning to miss in his life. He felt guilty about his rage, which he felt had predated his injury, but which he had put to good use on the football field. Sport was where aggression served him well – it helped him win and he could work out his feelings. His injury meant that he could no longer play football, so had lost a valuable outlet for his feelings at the very time that he needed it. At this time other members of the rehabilitation team were giving Nathan and his family detailed assessments and education about the

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potential effects of brain injury. This included difficulties in understanding and in dividing attention, potential problems in crowded places and extra sensitivity to any stimulation. This gave a context to the fact that his noisy younger brother could easily tip him over into a rage. Advice was given on rest periods, and Nathan was warned to expect that the effects of his brain injury would be worse if he was tired, tried to do too many things at once, felt stressed or drank alcohol. Once discharged from being an inpatient on the unit, Nathan attended art therapy as a day patient. It soon became clear that once again he was in a bad way. When he came to see me he was miserable and fed up with himself. He told me that he had had a bad experience at the huge local shopping complex. It was very busy and the crowds seemed to be coming towards him and about to bump into him. He had reacted by becoming upset and angry and lashing out. This sort of reaction had also happened on other occasions and he ended up taking it out on his family.

Figure 13.2 zzzz: disaster waiting to happen.

It seemed hard to know what to do. I noticed Nathan pushing up the edge of his folder. Would he like to start some drawing, I asked? He got some pencils and crayons, but paused again and told me he did not know what to do.

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‘Something about what you’ve just been telling me about?’ I suggested. He didn’t reply, but then drew for about 20 minutes (Figure 13.2). The image was of a figure in bed – feet first with a cartoon convention ‘zzzz’ showing it is fast asleep There are obstacles and dangers all around. Above the sleeping figure there is a ‘ton weight’ on a shelf with brackets clearly showing marks of strain. On the right is a stick figure aiming a bow and arrow, on the left there is a foot aiming a ball towards the figure. Both arrow and ball are mid air and about to land. Speech bubbles containing ‘HA HA HA!’ suggest triumphant or ‘hollow’ laughter. A sudden awakening would not mean escape; however, there is a skateboard on one side of the bed and a pile of toy bricks on the other. It is the moment before a disaster, with no escape route. Meanwhile the figure on the bed is dreaming (indicated by the cartoon ‘think bubbles’) that he is standing outside a front door, with a glum look and saying ‘I’ve lost my key’. Nathan said that all these obstacles were waiting for him and he could not bear the thought of getting injured again. This session showed him, as it showed me, the dread and despair that lay behind his extreme reaction to imagined aggression in the shopping centre. It also graphically records the moment before a disaster that will be impossible to escape.

Figure 13.3 Stress – can this game be won?

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The following week Nathan produced a picture which encompassed both the trauma and his current situation. Based on a computer game, there are two sets of figures, red and black, making their way round a danger-filled course. In the middle is a little head in a rectangle that could be a television or a games station monitor. There is steam coming out of its ears as if ‘ready to explode’, but the expression looks stressed, with eyes closed. Perhaps it is waiting for the end of the game, which looks imminent. None of the figures look as if they will survive long. Ropes are snapping, some of the parachutes have not opened, a figure hangs by its fingers over something exploding below. The sun has the same grim or ‘gritted teeth’ expression as the head in the middle, and echoes an earlier image of half a monster head which Nathan had entitled ‘heart of darkness’. Nathan appeared quiet and desperate in this session. He told me how ashamed he was about taking things out on his family at home. I realised that he had been going through a terrible time and that his aggressive outbursts were just a part of this. I felt concerned for him. (Note: When I contacted Nathan in connection with this article to see how he felt about his story and pictures being published, he looked again at this picture (Figure 13.3 above) seven years after making it. He pointed out that the picture tells the stories of two separate characters. The figure on the right of each pair is him. These figures (drawn in red) are all facing imminent annihilation, but each one has a chance to save himself – one has a pickaxe to stop him slipping into the pit, another a shield. Looking at the picture, he said, ‘This picture has got two sides; the right side is the good side.’ My reflection now is on the way that the artwork can take a lead in expressing feelings that he was not able to express in words (in this case a glimmer of hope that the disaster might be survivable).) The following week Nathan’s despair seemed to have evaporated. The image he made showed him in a different place: standing on top of the world and protected by a spacecraft. Footballs and missiles bounce harmlessly off the sides. The figure is raising his fingers and this time he is the one saying ‘HA! HA! HA!’ There is a full set of exclamation marks followed by the words ‘YOU CAN’T GET ME!’ He was clearly feeling better (Figure 13.4). This short series of pictures seemed to represent a significant part of therapy, the time when Nathan’s feelings were beyond understanding in words and when he most needed to express his feelings using art. Using the language of films, computer games and animation, Nathan was able to express the desperation of his situation (and his feelings). He explored this

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Figure 13.4 Invincible.

using conventions and references to films and games, with humour and suspense, overcoming obstacles in the race against time. Nathan had seen himself as out of control and full of rage and aggression, and therefore a bad person. He had become increasingly depressed. In art therapy he was able to explore the sadness, injustice and fear related to his accident. Once this had been expressed and understood, he was able to move forward. Over the course of the final six months of art therapy, Nathan began to work out what he could do with his life, now that competitive sport was ruled out. Eventually, he played again in an amateur league (Figure 13.5). The image below was made at a time before he began to play. It shows a footballer on the pitch. The caption says ‘Someone hitted Nathan’. Was it safe to play again? The big question mark could apply to the past and the future. However, the issue of anger did not go away. As Nathan had now gained trust in me, he was able to use the sessions to work through some of the reasons that he had had a problem with aggression before he was struck down on the football field. Eventually, he was able to reclaim the idea of having a ‘temper’ as something that was part of him, but not out of control.

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Figure 13.5 Back to normal?

In art therapy Nathan was able to look back at events in his past, and process his thoughts and feelings confidentially and at his own pace. He used images, ideas and stories that were familiar and meaningful to him, and did justice to the complex and difficult journey of recovery he was on. Acknowledging trauma and entering into a process of experiencing loss and grief, before being able to move on, is a painful journey that many people need to take after brain injury. When I talked to Nathan recently, and asked him about the lasting effects of his brain injury, he said it was a long time before he ‘could let his family out of his sight’, as he feared for their safety all the time. He added that his life had changed its course. Some things he realised he could never get back.

The place of art therapy in early rehabilitation Rehabilitation is of its nature goal-orientated, and pressure and feelings of loss and failure are common experiences. Art therapy may contribute in several ways. It gives permission to explore and accept emotions, and the client sets the agenda: there is no ‘right’ way of creating art. Confidentiality is also important: clients have often said that they are reluctant to talk to relatives

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about how they are feeling. It offers a continuous therapy relationship during a period of major adjustment (generally weekly sessions from four to 12 months), and it offers the opportunity to explore safely, and contain both conscious and unconscious issues, using words or using the art medium.

Some thoughts on anger, confidentiality and risk issues There do seem to be some particular issues for art therapists working with brain-injured people. Patients may be less inhibited owing to their brain damage. Disoriented people may mix you up with a trusted friend and may not be aware of your professional role. This might mean that they slip quickly into a trusting relationship and talk more freely to the art therapist than they would otherwise have done. Or, people may be less inhibited and speak aloud thoughts they would have normally kept to themselves. For example, one issue that might be expressed is a desire for revenge after being assaulted. The balance is to weigh up potential risk with the therapeutic benefits of clients being able to express strong feelings. Although verbal or physical threats need to be taken seriously, it is important not to break confidentiality unnecessarily, which could have the potential for setting off a train of counterproductive events for the client or the therapy relationship. My experience has been that, over the months, clients’ feelings often shift. Expressions of anger and rage are, after all, a part of the grieving process. People are much more likely to be able to move on if they have been given the opportunity to express such feelings. However, such expression is not always easy to listen to, and quite often people go over and over the same ground for a mixture of psychological reasons and because of cognitive difficulties. For others, anger is hard to access, sometimes (though not necessarily) for neurological reasons. The expression of anger has traditionally not been regarded acceptable for women, particularly those brought up before feminist ideas challenged gender stereotypes about anger in the 1970s.

Conclusion Whatever the neurological or cognitive issues brain-injured people face, whether they have difficulty moderating expression of feelings or whether they have problems expressing them at all, it is important that they are able to find a way through the psychological processes which affect people after severe trauma and sudden disability.

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Expression of anger is not regarded as particularly desirable in many cultures, including the UK and many northern European cultures. A high proportion of head injuries happen to young risk-taking men – a group regarded with suspicion and associated with aggression, notably in sport and when drinking. For some, anger is part of the complex mix of reactions – a reaction to trauma and part of the grief and mourning process, which needs understanding and expression, not simply management through drugs or behaviour modification. Whether or not clients have significant cognitive or communication difficulties, art therapy can provide the necessary time and space to develop a language to express and share feelings and thoughts about a life that has been suddenly changed by the disabling effects of severe brain injury.

Acknowledgement With thanks to Nathan for letting his artwork and story of recovery after brain injury appears here, and who gave me such valuable feedback about his rehabilitation.

References British Society of Rehabilitation Medicine (BSRM) and Royal College of Physicians (2003) Rehabilitation Following Acquired Brain Injury: National Clinical Guidelines. London: BSRM. Garner, R. L. (1996) ‘Factors in neuropsychological rehabilitation.’ American Journal of Art Therapy 34, 107–111. Johnstone, B. and Stonnington, H. (eds) (2001) Rehabilitation of Neuropsychological Disorders: A Practical Guide for Rehabilitation Professionals. Hove: Psychology Press. Laatsch, L. (1999) ‘Application of cognitive rehabilitation techniques in psychotherapy.’ In K. Langer, L. Laatsch and L. Lewis (eds) Psychotherapeutic Interventions for Adults with Brain Injury or Stroke: A Clinician’s Treatment Resource. New York, NY: Psychosocial Press. McGraw, M. (1989) ‘Art therapy with brain-injured patients.’ American Journal of Art Therapy 28, 37–44. Prigatano, G. P. (1991) ‘Disordered mind wounded soul: the emerging role of psychotherapy in rehabilitation after brain injury.’ Journal of Head Trauma Rehabilitation 6, 1–10. Rose, M. J. (1999) ‘Medical considerations in brain injury rehabilitation.’ In M. Giles and J. Clark-Wilson (eds) Rehabilitation of the Severely Brain Injured Adult. Cheltenham: Stanley Thornes. Sury, R.W. and Sano, M. (1999) ‘Neuropsychological impairment: challenges for therapeutic intervention’. In K. Langer, L. Laatsch and L. Lewis (eds) Psychotherapeutic Interventions for Adults with Brain Injury or Stroke: A Clinician’s Treatment Resource. New York, NY: Psychosocial Press. Wald, J. (1989) ‘Severe head injury and its stages of recovery explored through art therapy.’ In H. Wadeson (ed.) Advances in Art Therapy. New York, NY: John Wiley & Sons. Wisdom, C. (1991) ‘Art therapy. Words – the images of things. Painting – silent poetry.’ In C. J. Goodwill, M.A. Chamberlain and C. Evans (eds) Rehabilitation of the Physically Disabled Adult. Cheltenham: Stanley Thornes.

Chapter 14

Not Being Calm: Art Therapy and Cancer Hilary Brosh

Introduction Art therapy work in cancer care is now well established in hospices and hospitals, and literature on the subject is growing – see, for example, Connell (1998a, 1998b) and Pratt and Wood (1998). Further evidence of recognition of this work is the formation of ‘The Creative Response’, a subgroup of the British Association of Art Therapists (BAAT) formed in 1994, for art therapists working in the areas of palliative care, AIDS, cancer and loss, which holds regular study days for members to pool experience and offer information and support. Art therapists in cancer care deal with a range of emotions which patients bring to the work, but it is the aim of this chapter to focus on the major and pivotal role that anger plays through two case studies. In this chapter I will introduce the context of my work, discuss anger in cancer care and present two brief case studies, which will then be considered in relation to the literature of psycho-oncology in the concluding discussion.

Anger in cancer care Working at a cancer drop-in centre (the Robert Ogden Macmillan Centre, Leeds) I meet patients who are at various stages of the cancer experience, but, mostly, at diagnosis and whilst enduring different forms of treatment. Their responses to, and experiences of, treatment are varied. Not all cancer patients feel angry, but anger has been an issue for a significant proportion of the patients and families I have worked with. For example, described at ‘aggressive’ by her oncologist during a course of chemotherapy, a patient who had great faith in her doctor told of feeling an anger made up of confusion and

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fear about the poison entering her body, and expressed this anger in art therapy by bold and energetic red and blue painted lines representing the red drug entering her blue veins. Another concern that arose in the course of radiotherapy treatment was fear of the cancer, together with fear of being left alone with the huge machines, leading to anger being directed at staff. Dreifuss-Kattan (1990, p.47) writes of a patient having feelings of being ‘controlled and left at the mercy of a huge one-eyed monster’ in the radiotherapy department. Attending appointments for treatments at different hospital sites left yet another patient feeling angry at the long journeys that were necessary, backwards and forwards from home to clinics, and he made an energetic painting of multicoloured zigzags which graphically described his endless travels. Anger expressed is understood as one possible response to losses and changes that patients are feeling because of the cancer. There might be losses of bodily parts and functions as a result of surgery, loss of hair from chemotherapy treatment, changed body appearance from surgery and treatment, loss of energy and purpose, loss of role – either temporary or permanent – at work or at home, loss of sense of identity and being perceived differently by others on becoming a ‘cancer patient’, or a perceived loss of future dreams and plans. There is also the anger, panic and fear at suddenly being faced with one’s own mortality and a frustration for some at the difficulty of talking about death and spiritual matters. These unaddressed feelings might be added to other psychological problems which might have existed before the cancer diagnosis, so that for some people cancer seems to present an opportunity to address long-standing problems. ‘Anger’ could be said to be an umbrella term for many different kinds of feelings, ranging from a broad anger at God and the world, to an envy of a therapist perceived to be healthy and cancer-free, to a fury at a particular person for not saying something to a doctor at a particular time or, alternatively, a desperate sorrow at neglected and ignored dreams and plans. Barraclough (1999, p.71) classifies four different types of anger when working with cancer patients; this classification will be discussed in the context of art therapy practice later in the chapter. Whatever the type of anger, acknowledging it and verbalising its cause is considered important for good patient and carer communication. Faulkner (1994), working with patients with advanced disease, describes strategies for handling anger. She writes of the need for verbal expression to provide a means for individuals who feel isolated and distanced from others to address and communicate

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their feelings of anger in order to improve the patient–carer relationship. This need is similar to the provision in art therapy of time, space and an expressive language to enable cancer patients to work within a therapeutic relationship and tell their stories in their own unique way. Dreifuss-Kattan (1990, p.xiv) writes of the value of using ‘cancer stories’ as a form of ‘psychological self-repair in the face of multiple losses and as a reparation in view of one’s own death’. She quotes from artists and writers suffering from cancer, and discusses anger in the context of psychoanalytical ideas of mourning, loss and creativity, themes which I shall consider further in the concluding discussion.

Art therapy in a cancer centre Art therapy at the Robert Ogden Centre is available alongside other complementary therapies as part of a programme of psychosocial care to offer support to patients with cancer and their families. They have entered the world of oncology, with a language and meanings often difficult to understand, and even though good clinical care from support nurses and doctors can address initial shock and fear, reactions to a cancer diagnosis vary enormously. If anger is felt it is an understandable response to the losses and changes that happen after a diagnosis, while undergoing treatment and when living with the fear of its return once treatment is finished. To access art therapy, information leaflets describing art therapy as a means of looking for a different way of expressing emotions, are circulated around wards and clinics. Patients and families can call in at the Robert Ogden Centre to find out more or to book an appointment to meet me and arrange an introductory session. Apart from a few introductory groups, art therapy is generally offered as individual sessions. For many people, art therapy is a relaxing and peaceful space away from medical environments, and it is also understood that the images created might not all be pleasant and happy, but might also deal with feelings such as fear and terror that patients find it hard to talk about. Luzzatto (1998) describes the unique feature of art therapy, in that it allows space and time for working with the negative feelings present in cancer care where there is a strong culture of positive thinking. Dealing with complex and negative feelings is problematic as the general advice given to patients is to stay calm and positive in order to have a better chance of recovery. In the military metaphors used about winning the battle against cancer, described by Sontag (1998), the lack of a positive attitude might even be seen as ungrate-

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ful and inappropriate, and working against the best efforts of all the medical team trying so hard to conquer the disease with their huge arsenal of treatments. Cancer patients also have the problem of how to deal with this anger without further upsetting family and friends, and they will feel the need to be calm and positive in order to help them to cope. For some people, weekly sessions at the centre become the only place where tears can be shed and feelings unable to be spoken of elsewhere may be unloaded and reflected on in a non-judgemental and confidential therapeutic environment. When words are difficult to find or use to describe intolerable feelings, art therapy offers an alternative form of communication and coping. When I meet a new patient, the confidential nature of sessions is explained and understood as somewhere safe and separate from the polite social interaction of the rest of the centre. The limited range of art materials – oil pastels, chalk pastels, water colours and poster paints, and clay – is introduced and explored as a means to facilitate self-expression. The only requirements are that the patient is willing to use the art materials and to have a facility for self-reflection. I have always looked for a spark of curiosity in the patient about the art materials, which I can connect with and encourage, knowing that an image of some sort will always emerge. The value of using art materials with cancer patients for self-expression of anger is well-described in the literature of art therapy (Connell 1998a, pp.43, 62, 82–84; Coote 1998, p.58; Thomas 1998, p.73). The kind of angry paintings familiar to most art therapists are also seen in cancer care – sheets of paper covered in red paint, energetically and boldly applied, completed with either tears of frustration and rage or great sighs of relief. I work with patients for hour-long sessions, which take place in a multipurpose carpeted meeting room without a sink – not an ideal setting, but private and containing the essentials of work: art materials and a relationship with a therapist. The drop-in nature of the Centre means that some people are seen only once or twice, but most work is contracted and the people in the two cases discussed below were seen for three to six months.

Case studies Case study 1: The brown smudge Patients with cancer and their families are offered support at the Centre and the subject of this case study was a carer. My client came to the Centre feeling exhausted and overwhelmed with her problems. She was in her mid-thirties,

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had a father at home with terminal cancer, a husband diagnosed three years previously with cancer and still in treatment, and three school-aged sons. She was working in a school as a teaching assistant, which meant that she was familiar with art materials although she had not done any artwork of her own. At our first meeting she was very tearful and talked initially about her mother’s death, 13 years previously, and how much she needed her now. I asked her to use the art materials in any way she wanted in order to tell me something about herself. Her first image in chalk pastels was made tearfully, starting with a green shape representing her mother because green was her mother’s favourite colour, and her feelings of being in a tunnel and feeling very angry. She described the marks representing her sons, her father and her husband, but did not refer to a small orangey-brown smudgy mark in the corner. When I asked her about it, she said very tearfully that it was how she saw herself – a smudge surrounded by anger. I then asked her to do a second image, just about herself. She chose to use oil pastels – a stronger medium and one less likely to be smudged – and described her love of travelling, her three sons and how she had always wanted a daughter to recreate the mother–daughter relationship she had lost. The second picture was more energetic – bold broad marks accompanied by further tears. It had more space and was uncluttered by marks representing others in the family, but once again expressed a lot of anger. We ended the session by discussing concerns that we could work on in art therapy. We agreed that these should be, first, for her to have some space and time for herself in order to be able to express her anger in safety, and, second, for her to engage in self-exploration in order to discover her own strengths and start to believe in herself as more than a smudge in the corner. At our second session, the client was again very tearful and told me that she did not cry at all at home because she did not want her children, father or husband to see her upset – she felt that she just had to get on with things. She was very protective of her sons and did not want them to feel the pain that she felt, saying that if they cried together, then she became the comforter. She continued to cry about her mother’s death and it sounded as if her family was one in which emotions were not expressed. The stress at home was greater than normal that week as her husband was having radiotherapy and was not feeling too well. Her painting for that session was large and assertive, containing a self-image as energetic and bright, alongside images of death and cancer, and colours representing her mother and father. The client was able to tell me that she valued the sessions as somewhere she could

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cry and relax while painting. In subsequent sessions she became less tearful, and, two months later, I wrote in her notes that for the first time she had not cried. Although she found talking about feelings difficult, she was able to reflect on her paintings and what they meant to her as a way of sharing what was happening in her life. We continued sessions for six months and as her paintings became a source of pleasurable activity and some pride, my client’s self-esteem increased. In her world, where she felt little control over the life and death issues surrounding her, she was able to feel some control of paint and her images. Predictably, issues other than cancer began to emerge in the images and discussion. She was finding work difficult, feeling that it was becoming a reflection of her home life, with a lot of manual work and little scope for creative or personal fulfilment. She also realised that she paid little attention to her own health and well-being, and perhaps as a result of experiencing some care and attention in our therapy sessions, she started to make time for herself to go swimming and to see friends. After a couple of months, she was able to think about applying for other jobs. It was of enormous importance and value to this client that she did eventually find a better job, where she was not just doing domestic work all day but had some status and challenges, as well as a proper career structure for some future time when she might be the sole parent. After six months of weekly sessions, her self-esteem was such that she was able to cope with her father’s death, her husband’s illness and the demands of her growing family. Some years later I wrote to her to ask her permission to use her story and received this reply: It was good to hear from you. We are all keeping well, thank you. Yes, I give my permission for you to use my work. The art therapy was a fantastic help to me. I feel looking back that I was very close to a nervous breakdown and the art therapy was my release and helped prevent a breakdown. I still look at colours and think of my parents and the things we talked about. Thank you for being there for me.

Case study 2: A present When this client first came to see me, it was with a very specific request – to help him make a painting. He had never painted before, but wanted to make this painting as a present for his son to enjoy after his own death. He explained tearfully about the death of his wife and his closeness to his adult son, living in London. His son treasured a little picture, made by his late wife

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in the last months of her life when she was in hospital, and, after receiving a poor prognosis himself, he wanted to create something that his son could also remember him by. At this point, I was wondering what sort of picture he wanted to make. Would it be a technically difficult oil painting, or one of a particular person or place? I was surprised when he told me that he had been into an art shop and seen an abstract painting which had had an amazing impact on him and which he was very keen to copy. He was very specific about the importance of the quality of blue, and that it should also have some gold and silver in it. We discussed the painting, and planned out the stages of work involved. Before the next session, I went to the art shop to see the painting in order to try and understand its importance. The deep blues, gold and silver certainly caught my attention and made me think of medieval religious paintings. I was aware of blue as a colour that is associated with heavenly skies and spiritual qualities, and it seemed that the painting was not only intended as a present for his son but might also be about life after death, and about the artist trying to cope with, and understand, his own death. Talking in self-reflective or psychological terms was very difficult for the client, and the focus of the art therapy work was on the technicalities of making the painting. The activity of painting was very relaxing for him, and as the painting progressed he came to feel more comfortable with talking about himself. There were days when he felt particularly low. He was distressed to find out that his dog also had cancer, and he was himself tired and sore from radiotherapy treatment. The background of the painting was varied tones of dark and lighter blues, and one week he came in, looked at the painting, and asked me if I thought that the dark part was too dark. He asked whether, when his son looked at the dark parts of the painting, he would think only of his father’s death and dying. We looked at the dark part of the painting together, and he told me that he had been thinking recently about his death and his fears of dying. He had bad memories of the time after his surgery when not enough pain relief was given, and he had come out of the anaesthetic in extreme pain. Usually a very gentle and quietly spoken man, the client spoke of these memories very emotionally and felt a great deal of anger towards the nursing staff. He told me the story of his time in hospital and the investigations, interventions and surgery that he had experienced, during which his relationship with his medical team had been compliant and appreciative. However, his memory of pain had stayed with him in his nightmares. His anger was released by focusing and reflecting on the dark part of the painting, and this enabled him to talk about fears that he

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had previously been unable to talk to anyone about. I encouraged him to talk to his medical team and his Macmillan nurse about pain relief and his fears. At the end of that session, he looked at the painting and said to me that the dark part no longer looked so dark. He continued working enthusiastically, needing only support and technical help from me. He remarked how low his self-confidence had been once cancer had been diagnosed, and how much more positively he viewed himself since he had finished the painting. The painting was planned in stages of background colours, foreground shapes and a final addition of some gold and silver leaf. My thoughts about the spiritual content of the picture were confirmed when he told me that he would like to include a star in a top corner. The painting was signed, varnished, mounted and framed to his very exact specifications so that it would look professional. Before assembling the frame, an intimate and private message to his son was written on the back of the painting and concealed by the frame, possibly to be found and read in the future after his death. He was very pleased with the end result, and before he gave it to his son he offered it to the Centre to use for publicity purposes, as he was known to the local paper because of his work for another charity. His son was delighted with the present and the painting hangs in pride of place in his London flat.

Discussion and analysis I would now like to consider some functions of anger in cancer care, as described in the literature of psycho-oncology and psychoanalysis, in relation to art therapy and to the case studies presented above. I have described the expression of anger in the case studies as having an important function in uncovering and releasing other strong emotions otherwise unable to be expressed, and how working with art materials offers a unique opportunity for finding another language to tell our story and to express anger in safety. Barraclough (1999, p.71) classifies four different types of anger in working with cancer patients. ·

‘Free-floating’, when the patient is angry about the unfairness of the illness, possibly blaming fate or God.

·

Displaced, often towards healthcare staff.

·

Justified, for example when there has been a delay in making the diagnosis or treatment that has caused more harm than good.

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Suppressed, so the patient does not acknowledge being angry and, indeed, may not be consciously aware of this emotion, but expresses it indirectly by appearing negative and unco-operative, becoming depressed or developing somatic symptoms.

The anger of my first client, (case study 1) was initially suppressed and concealed, and seemed like a volcano waiting to erupt. The client’s tearful expressions of anger seemed ‘free-floating’ and ‘justified’ (Barraclough 1999, p.71) in the way that she saw that cancer had affected all the loved ones in her life. Her need for therapy was about bereavement for her mother’s death 13 years previously, as well as about her present situation, and anger in this context is understood as ‘a normal phase in the process of adjustment to a cancer diagnosis, to bereavement or any other event involving loss’ (Barraclough 1999, p.69). A carer is not expected to be angry but to be patient, gentle and nurturing, and this devoted mother, wife and daughter came to the Centre in some desperation. Verbal counselling might well have provided an opportunity for ventilation of feelings, but once the energy in her anger was harnessed, the physical, creative production of tangible objects made possible a different means of self-perception. After the tears had been shed, her previously untapped creative energy allowed a new form of self-exploration, discovering strengths and possibilities in her life not previously thought possible. Reviewing the large amount of work produced at the final session, her increased self-esteem and confidence was a joy to see as she prepared to start her new job and have some optimism again for life. The anger contained in the production of the blue painting by my second client (in case study 2) could be said to have been ‘displaced’ anger directed at the nursing staff, as well as being ‘suppressed’ (Barraclough 1999, p.71) behind a very compliant and gentle personality. For someone who did not express anger easily, a target for his ‘free-floating’ anger was found in the nurses in post-op. It seemed that the anger served an important purpose in exposing terrors and fears about dying, and allowing the unspeakable to be spoken. As we looked together at the dark part of the painting, the visualisation of fears of death and dying needed to be received sensitively and acknowledged before they could be spoken of in the art therapy session or to staff who could offer practical help and advice. In both case studies there was an opportunity for resolution of the issues that had been the reason for coming to therapy, and in both cases the opportunity for their story to be communicated was an affirming one. The impor-

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tance of telling the cancer story, including any negative feelings of anger, despair and fear, is described in the work of Dreifuss-Kattan with artists and writers who have cancer: Writing about the fear and the pain of loss is itself a process of accepting and overcoming these emotions. The cancer author confronts his adversity and his new self; this confrontation is an affirmation of life. (Dreifuss-Kattan 1990, p.7)

This work resonates with the processes involved in the making of images in art therapy. Faced with our own mortality, creative work in any medium can allow the opportunity for some ‘psychological self-repair’ (Dreifuss-Kattan 1990, p.xiv). For some people, their cancer stories are an opportunity to address longstanding issues that were causing them problems before the cancer was diagnosed, such as previous bereavements, family dynamics or personality problems. If their family is one in which the expression of anger is never allowed, then having to deal with powerful feelings of anger as well as cope with the physical illness is particularly hard, and a history of how anger in the family has been dealt with in the past can be illuminating for both patient and therapist. Anger has two manifestations: it may be expressed very overtly in aggressive outbursts of rage, or it may be suppressed. In the case study 2, the client’s suppressed anger led to feelings of depression and the perception of himself as being bad, whereas in case study 1 working through the anger in a very expressive way produced feelings of everything in the environment being bad and hostile. Such feelings of ‘displaced’ and ‘free-floating’ anger are experienced by staff in cancer care, as there are patients and their families who deal with anger by finding someone – usually a doctor – on whom to project it. This is understood (Dreifuss-Kattan 1990, p.37) as the need for ‘finding an outside aggressor on to whom they can project their intense rage at having lost a part of themselves’. Rather than abuse being directed at doctors by patients, making images about the medical team in a variety of art materials can provide a much safer option for everyone to deal with this anger. An art therapy session might be explained to patients as being a place where such powerful feelings can be safely expressed, with an understanding that they can use art materials in any way they like as long as they do not harm the therapist or themselves. The provision of a safe place to express her anger was certainly a significant factor for the client in case study 1, and once a therapeutic relationship was established, she felt able fully to unload her feelings. Outside the sessions,

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she appeared calm and quietly spoken, but the anger unleashed behind the calm façade supports the view of psycho-oncologists that, for those cancer patients and their families who do struggle with dealing with angry feelings, the expression of their anger can facilitate a healthy adjustment to their situation. The client’s letter to me after therapy had finished is also evidence that, for her, being ‘calm’ was not a healthy option. Case study 1 described art therapy being used for bereavement work after a parent’s death and for many other losses. The bereavement process, and the function anger plays in it, is very much part of art therapy work in cancer care, with image-making having a unique role in containing angry feelings. Dreifuss-Kattan (1990) describes anger as having a reparative function as part of the mourning for losses experienced in cancer. Once the numbness of initial shock is over, the reality of loss is recognised and the cathartic expression of anger is evidence of a sense of self still existing. The process of image-making in art therapy reflects something of this function. In the transferring of feelings from self to image, some separation and distancing from feelings of loss is created, and the cathartic expression of feelings which exist in the tangible art object further validates and loudly proclaims the pain and anger being felt. The physical form of the image is also evidence of the existence and survival of the image-maker. A powerful and important message that art therapy can send is that even in a sick body, a creative part of the self is very healthy and worthy of some attention.

Conclusion Anger and its images have always been present in individual and social psychological responses to cancer, from early theories of suppressed anger being a cause of cancer (Sontag 1988) to the harnessing of aggressive imagery to boost the immune system. For example, there is anger and aggression in the many military metaphors used in individual and social constructs of attitudes to cancer, as in to ‘fight the battle’ and ‘win the war’ against disease. However, I feel that there has been some cultural shift in this attitude as advances have been made in treatment. Cancer may, in many circumstances, be thought of as a treatable disease rather than a killer, and hence, whilst cancer can still be seriously debilitating or even fatal, military metaphors now seem somewhat outdated. Nevertheless, in the current climate, whilst acknowledging the need for relaxation and a peaceful environment to help the mind and body recover from the trauma of cancer, it is necessary to acknowledge that for some individuals angry feelings still do

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exist. The view of psychologists and therapists referenced in this chapter is that where anger occurs, it needs to be addressed. Once it is recognised that it is not always possible to be calm, art therapy may provide an opportunity to contain and address the different types of anger described by psycho-oncologists, and can facilitate the use of individual and personal language for the expression of that anger. Most importantly, there is the awareness gained that there need be no sense of shame in making an image showing the anger felt in response to the devastating effect that cancer can have on patients and their world, and the realisation that nothing will be destroyed by the anger. The image, the therapist and the patient can survive the anger within the secure boundaries of the art therapy session.

Acknowledgements Thanks are due to clients at the Robert Ogden Centre and to Professor Peter Curwen for his invaluable advice and support.

References Barraclough, J. (1999) Cancer and Emotion: A Practical Guide to Psycho-oncology. Chichester: John Wiley & Sons. Connell, C. (1998a) Something Understood: Art Therapy in Cancer Care. London: Wrexham Publications. Connell, C. (1998b) ‘The search for a model that opens: open group at the Royal Marsden Hospital.’ In M. Pratt and M. Wood (eds) Art Therapy in Palliative Care: The Creative Response. London: Routledge. Coote, J. (1998) ‘Getting started: Introducing the art therapy service and the individual’s first experiences.’ In M. Pratt and M. Wood (eds) Art Therapy in Palliative Care: The Creative Response. London: Routledge. Dreifuss-Kattan, E. (1990) Cancer Stories: Creativity and Self Repair. Hillsdale, NJ: Analytical Press. Faulkner, A. (1994) ‘Dealing with anger in a patient or relative: a flow diagram.’ Palliative Medicine 8, 51–57. Luzzatto, P. (1998) ‘From psychiatry to psycho-oncology: personal reflections on the use of art therapy with cancer patients.’ In M. Pratt and M. Wood (eds) Art Therapy in Palliative Care: The Creative Response. London: Routledge. Pratt, M. and Wood, M. (eds) (1998) Art Therapy in Palliative Care: The Creative Response. London: Routledge. Sontag, S. (1988) AIDS and Its Metaphors. London: Penguin. Thomas, G. (1998) ‘What lies within us: Individuals in a Marie Curie Hospice.’ In M. Pratt and M. Wood (eds) Art Therapy in Palliative Care: The Creative Response. London: Routledge.

Chapter 15

‘Came Back – Didn’t Come Home’: Returning from a War Zone Annette Coulter

Introduction This chapter describes long-term art therapy treatment with an Australian Vietnam war veteran, and demonstrates how engagement with art materials may facilitate the safe expression of anger. For this combat survivor, art expression provided a release for traumatic visual images and explicit memories. Central to this process was the internal and external expression of rage, hate, hostility and resentment, which were the debilitating effects of unresolved post-traumatic stress disorder (PTSD). Art therapy also provided an expressive outlet for self-harm, such as suicide attempts, self-mutilation and binge drinking. Particular aspects of this case demonstrate how art therapy provides a means to communicate strong negative emotions for which verbal language is ineffective. The client, PD, gave permission for his artwork to be shared, so that the effects of PTSD and dissociation on war trauma survivors might be better understood.

The Vietnam War Between 1964 and 1973, the USA committed troops to the Vietnam War. Australia’s involvement began in 1965. Before the outbreak of war, the USA administration committed economic and military support to the resistance movement in the southern region of Vietnam, influenced by the ‘Domino Theory’. This theory held that if South Vietnam fell to the Communist regime, this would be followed by the fall of Laos, then Cambodia, Burma,

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the Philippines and maybe even Australia and New Zealand – a ‘domino’ effect. This led to the attitude that ‘if we don’t fight them in their backyard, we’ll be fighting them in our own backyard’, reminiscent of the White Australia Policy (Cathcart 1993, pp.411–412). By 1967, there were 6300 Australian troops involved, 40 per cent of whom were conscripts. Public demonstrations opposed Australia’s involvement in the conflict and gained momentum throughout the duration of the war. Australian troops were eventually withdrawn in 1973. It was a guerrilla war, with no defined enemy and no defined front line. There was no ‘safe territory’ and troops were likely to be attacked anywhere and at anytime. On their return home, troops were not welcomed and often arrived out of uniform to ensure their safety. For Vietnam veterans, the negative experience of homecoming, of being the target of public political rage and anger, invoked a secondary trauma, where ‘ridicule and denigration’ led to ‘longstanding maladaptive patterns of substance abuse, violence and dependency’. When there is no appreciation or support for surviving war veterans their inner world becomes ‘highly demoralized and compartmentalized’ (Miller and Johnson 1997, p.384). Trauma occurs where shocking and terrifying events are experienced that overwhelm the individual who experiences or witnesses them. Miller and Johnson (1997, p.384) describe the psychological mental state of Vietnam veterans as ‘one of intense alienation, constriction and negative self-image’. Symptoms are often misdiagnosed as psychological illness, such as hallucinations and flashbacks, various dissociative states, violent outbursts, psychosomatic or hysterical symptoms and addictive behaviours (Van der Kolk 2003).

Referral to art therapy In 1968, at the age of 18, PD volunteered to serve with the Australian armed forces in South Vietnam, assigned to the ground battalion. He came from a family tradition of honour and commitment to army service – his father had a military history and when PD decided to sign up, one brother was already serving in Vietnam. Like many other young Australians, PD believed he was doing the right thing to protect his country from communist expansion in Asia. He served six months as part of the rifle infantry of the platoon. The total platoon included 40 soldiers, but the rifle infantry was a front-line section of seven men. It was the section which attracted enemy attack and prepared safe

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passage for the rest of the platoon. Sometimes they were on their own, but most of the time they were just ahead of the rest of the platoon. PD witnessed soldiers dying right beside him. On his return to civilian life, traumatic experiences debilitated PD psychologically. He lived as a recluse for 20 years, unable to face the outside world. He lived with his mother, a widow. His two older brothers lived away from the family home and had little involvement with PD. Two years before referral for art therapy, PD had referred himself to a local repatriation hospital for treatment, motivated by a wish to lead a more ‘normal’ life. In hospital he was diagnosed with PTSD and placed on a highly addictive, antidepressant type of medication. He was increasingly resentful about this dependency. The Vietnam Veterans’ Counselling Service referred PD for adjunctive art therapy treatment. The purpose of the referral was to support PD’s reintegration into society and to help with the processing of PTSD symptoms such as dissociation, self-harm and social phobia. The Service continued to manage the case, but art therapy was provided in addition to this support. Initially, the Counselling Service funded therapy and then a concessionary fee was negotiated for weekly, one-hour sessions, by regular appointment. PD decided to fund his art therapy treatment himself to invest in his recovery. PD had begun producing artworks prior to commencing art therapy. He described an innate urge to express thoughts and feelings that were difficult to convey in words alone. He had completed a large piece of artwork (Figure 15.1) for the Vietnam Veterans’ Counselling Service, in memory of comrades who had perished in the war zone. The drawing is a complex array of crosses of varying size and expresses PD’s survivor guilt. Each cross is labelled with the name of someone whose death was brought about by the Vietnam War. The larger ones in the foreground are in memory of close friends, while smaller ones are soldiers he knew by association or not at all. Bordering the work are two elongated dragons, with heads and tails meeting at the middle top and middle bottom of the picture. The centre features two war veteran silhouettes against the Australian flag, one is a skeleton figure surrounded by blackness, the other a shadowed combat figure. On referral, PD’s symptoms were hyper-alertness, recurring nightmares, flashbacks, suicidal ideation, depression, self-destructiveness, substance abuse and other forms of anxiety that prevented adjustment to a ‘normal’ lifestyle. He felt permanently damaged, ineffective, ridden with shame and misunderstood. He had lost the ability to trust and felt victimised. He

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Figure 15.1 Vietnam. (Cardboard, felt pen, biro, acrylic paint) (Reproduced with permission of the National Vietnam Veterans Museum, Phillip Island, Victoria, Australia.)

suffered from a persecutory belief that his survival was due to the death of veteran mates. Self-inflicted injury included overdosing on his antidepressant medication. He had lost his sense of identity as a brave soldier defending his country, and, with this, an inner sense of self. Art therapy treatment took place over 18 months, during which PD experienced an improved quality of life and an emerging sense of self-worth. He developed personal relationships and was able to cope with crowds and public transport. He dressed more brightly, was less dishevelled and started selling his art work. He gained an emerging ‘artist’ identity, to convey a message on behalf of fellow soldiers who did not survive. When art therapy ended, PD was confident enough to continue art-making in his home studio.

The role of art media Art media may be used for exploration and self-expression in a variety of ways: through spontaneous, accidental forms with found objects; with traditional art materials; and through theme-centred art therapy work. Both twoand three-dimensional works can express and reconcile internal conflict,

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fostering self-awareness and personal growth. PD selected and explored a broad range of art materials during his trauma recovery. PD’s body of artwork exemplifies Lusebrink’s Expressive Therapies Continuum (1990), which describes three levels of involvement with art media in a therapeutic context. At the bottom is the Kinaesthetic/Sensory Level (K/S Level) of flexible media, such as paint and clay. In the middle is the Perceptive/Affective Level (P/A Level), which includes media such as oil pastels, collage and charcoal – this middle level links the three, so it is important for treatment planning. The top, more sophisticated level is the Cognitive/Symbolic (C/S Level), focusing on controlled media such as coloured pencils, pens and fine motor activity. Through observing a client’s approach to media, the therapist can work out their client’s level and then involve other levels of art media and tasks, so that all levels of the Expressive Therapies Continuum are mobilised to achieve creative potential. PD’s use of a wide variety of art media, working symbolically, spontaneously, methodically and cognitively, demonstrates the Expressive Therapies Continuum in practice.

Anger issues Treatment for combat survivors may be described as involving three phases of creative therapy treatment (Miller and Johnson 1997), dealing progressively with rage, then shame, then empathy. Rage is anger that has got out of control. The focus of this chapter is on the first phase, where anger and rage are addressed. Anger is a strong emotion that is difficult to define, but refers to a violent or passionate emotion or ‘hot displeasure’ (Bowlby 1973) that blurs into reactions such as rage, hatred, hostility, wrath or aggression. In this case, the context in which PD uses the term ‘anger’ refers mainly to resentment. When he first returned from Vietnam, PD tried to lead a ‘normal life’. For a short time, he had a job laying pipes. To demonstrate the degree of anger he was carrying, PD recounted that he broke five hammers in one week, whereas others had only broken one hammer in all their years in the same job. In recollecting this story, PD warned of the intensity of anger that is turned inwards, with self-harming consequences such as binge drinking, suicide attempts and self-mutilation. Engagement with art-making processes provided a channel for internalised and repressed anger, disillusionment and alienation to be externalised and explored in therapeutic safety. Symbols and repressed war images, as

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well as accidental, risk-taking adventures with art media provided an opportunity for free association as images of hope and personal metaphors sought expression. This process of externalisation through symbolic image-making provided a container for unresolved anger.

Starting treatment: the visual diary When art therapy treatment began, PD’s mood was oscillating between anger, resentment and an internalised depression of hopelessness and futility. Visual journalling was encouraged (Ganim and Fox 1999; Hieb 2005) to provide an ongoing personal process between sessions. A visual diary is similar to a written diary, but with a visual starting point. It is private, and there is no expectation that the visual diary is shared with the therapist – it provides a safe place to process freely. Entries are made at any time with any type of art media. It is encouraged that entries are sequential and documented with at least the date, time and a title (even if it is ‘untitled’). Items are pasted in, written material is included, such as a poem, a thought, a quote, a joke, a cut-out image or any other items that are significant to the ongoing diary process. Although it is for personal use, particular images from the visual diary may be brought to therapy and shared, if clients wish. PD began his visual diary with a photograph of himself as a young soldier, and this poem written alongside: PD was just a baggy arse, a private, a crunchy, a grunt, He liked to have a drink with his mates, 1 And enjoyed a laugh, a prank and a punt. He went to Vietnam, He went by ship and by choice, He thought it was the right thing to do, Brain-washed by liberty’s voice. But he went for a bit of adventure as well, Hoping to return with a medal or two With a mind as sound as a bell. Childhood dreams were pushed aside though By death, blood and fears, 1

‘Crunchy’ means infantry soldier (so named by the marines because they walked through the jungle); ‘grunt’ is an ordinary soldier; ‘punt’ means to place a bet.

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And all that remained when he came back Was hate, anger and tears. It was a pity too, for well I knew him When his life was so care free, Oh yes, I knew him so well Because poor old P.D. was me. (P.D. Born 1947, died 1968)

Maintaining a visual diary gave PD continuity and also contributed to the holding of painful material. An early image from PD’s visual diary depicts a bloodshot eye peering out at the world from behind a closed blind, his living situation for 22 years. A double diary page is shown in Figure 15.2. It is about having nine lives (like a cat) and having nearly used them up with his suicide attempts and self-harming.

Figure 15.2 Visual diary: Nine lives (felt pen and acrylic paint on paper).

Art therapy processes Visual journalling led to further personal processing between sessions on canvas boards. Consumed by an urge to create, PD spontaneously began to produce home studio artwork, extending themes related to his therapy sessions. Naumburg (1987) supports clients bringing completed artwork to

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the next art therapy session. Working in his home studio encouraged a sense of independence in PD, promoted his self-confidence and fostered an increasing ability to understand his images. Moreover, in order to venture outside to buy canvas boards, paint and other art equipment, PD addressed his phobic fear of crowds. So it did not seem appropriate to discourage this creative energy. Weekly sessions often began by viewing artworks completed between appointments. Discussing the work sometimes led to greater understanding of symbolic content and providing material for the session. For PD, arriving with completed images and sharing a new technique or emerging theme was an important part of the process. Even if an image was not completely understood, he began to appreciate that ‘not knowing’ had potential to be significant.

Expression of anger in early work Physical self-harm to express anger occurred in an early artwork PD completed at his home studio, where he combined self-mutilation with art activity. To achieve this work, PD slashed his forearm and allowed the blood to drip over paper (Figure 15.3). Recollecting this process, he described cutting his arm and being mesmerised by the patterns of dripping blood, numb to any pain. This physical self-wounding was sublimated into creative activity (Menninger 1938, Milia 2000). PD experienced a sense of dissociation or fragmented consciousness, of being disconnected from himself. The smell of drying blood also triggered flashback recollections of death and decomposing bodies. Self-harming and self-destructive behaviour continued throughout art therapy treatment, often a psychological regression after a new personal insight. Another early work was a symbolic release of anger in the form of a sculpture of a contorted figure. Walking home from an art therapy session, PD’s attention was caught by a dried plant root. He associated it with a wounded body, painted it red and black, and mounted it on a fibreglass base. He gave it the title ‘Died in Vietnam’. Lusebrink (1990, p.100) emphasises the importance of ‘haptic’, accidental, spontaneous qualities in artwork. This exemplifies symbolic work initiated by found objects, transforming explicit memories of the present into aesthetic objects for the future. At the time of referral, PD described anger and resentment towards people who did not understand. Had he lost a limb, people would have seen the injury and his suffering might have been better understood. PD felt

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Figure 15.3 Untitled (human blood and acrylic paint on paper).

tagged by the label ‘PTSD’, a disability that was unseen because the damage was inside. He was concerned for the suffering of combat survivors and the futile waste of lives for a war that for him, on reflection, had no purpose. Figure 15.4 demonstrates how an emerging theme of anger and frustration began. PD stated that ‘even insignificance can be beautiful…’ [indicated top left]. ‘…The eye is a symbol of insignificance with a beautiful heart. It is like looking inside something and seeing something inside that…the red is two front feet’. He continued with a Gestalt description: I’m a beautiful thing inside – I’ve just grown stagnant – but I’m still alive…I can’t go forward unless I change into what I’m meant to be. That’s why I’ve no legs at the back to push along…I’m still waiting to get out of the hole – trying and all the time, the harder I try the worse it gets.

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Figure 15.4 Insignificance magnified (acrylic paint on paper).

Reflecting on this artwork, PD continued: …doing art is getting in touch with it. I wanted to go back to Vietnam…I would have got myself killed…I missed the opportunity of going back and finishing myself off. I never really did come home – I’m still there. [Re: central circular shape.] This is the bit that didn’t come home – it’s trapped inside. Outside is what did come home. People see me, they don’t know my heart is not here…There has got to be a reason why I survive – I can’t understand the elimination process – why one bloke gets killed and another standing beside him survives…

Anger and resentment series PD went on to explore further ‘the bit that is trapped inside’, resulting in a series of four artworks that connect to anger and resentment. In Figure 15.5 the central shape ‘that didn’t come home’ from Figure 15.4 is enlarged. About Figure 15.5, PD said, ‘The edge is starting to disintegrate.’ In the next picture (not included here) he continued the exploration, ‘The centre’s changed. A barrier is starting to grow at the edge and the disintegration is going out of the picture.’

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Figure 15.5 Metamorphosis (acrylic paint on paper).

The process continued with Figure 15.6. A detailed explanation unfolded: It is alive and vigorous, but is trapped inside behind the wire [edge barrier], there’s no way out and it stays there for a long time. This represents 22 years [the number of years since PD’s return from Vietnam]. I’m still hoping that something’s going to happen, that I’ll get out and be free of torment. The black lines are possible roads to recovery but there’s no way out. They represent Life [top left], Hope [top right], Reality [bottom left], and Future [bottom right]. Other crosses are other roads I’ve tried but they’ve all been failures. The yellow streaks [near each cross], are attempts down these other roads but they’ve turned out to be nothing. So four have potential but the barrier/wire stops me – it’s like the wire at Nui Dat…it’s like when I came home, my friends became my enemies, going to see them was like going on an operation, like an exercise in the jungle. I tried different ways. I cut my face to change my face, I’d become different but it didn’t work. I tried every avenue that’s there to feel like I’d come home… – I’m still not home. I feel like I’m in a dream state – that I don’t exist, that I’m not really here. Someone else has come home in place of me. The PD that’s here is not the PD that left. The PD that left is still over there – there’s no hope. He

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doesn’t like being over there – he wants to come home…The brown internal barrier [heart shape], is protecting the centre from being hurt, it’s been hurt in the past – its frightened.

Figure 15.6 Vitality (acrylic paint on paper).

Although PD had returned from the war zone, it felt as if he was not really here. To conclude this series, PD articulated his resentment in Figure 15.7 ‘Came Back – Didn’t Come Home’. The black lines are the roads to recovery, ‘I’ve gotten help now and the barrier has broken for me. People tell me I can go down these roads but it’ll take time. I’ve just seen something, it could have been “Came back – Will never come home,” so that’s a bit of hope.’ The image is of a red, yellow and black skull-like shape, in the middle of black circular shape with four heavy diagonal lines going to each corner and two or three rounded bump-like shapes between these four, representing other attempts to go down roads that met the barrier. A brown barrier protects the central skull shape, around which are the words ‘What a terrible and lonely dark and bitter place hell must be if it’s any way worse than life itself.’ Dealing with anger about a sense of hopelessness was part of the therapeutic process.

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Figure 15.7 Came Back – Didn’t Come Home? (Acrylic paint on paper.)

This theme of anger continued to surface. To address this directly, I invited PD to represent these feelings of resentment (see Figure 15.8 ‘Anger’). He commented: My anger is inside the circle, and it can escape and hurt people. I often wonder – why haven’t I killed anyone? I turn it into myself a lot of the time and hurt myself because I really don’t want to hurt others. If all of them [pointing to zigzag lines] came out I’d be very dangerous. The normal parts that others see are brown, fragmented, they have no real shape. They are still there because I am still human…I turn the knife [top right] onto myself instead of these people. If the anger came out, I’d turn it onto other people…Psychiatrists forget they’re dealing with men who are trained killers and that they have killed – better not forget that…The black is feelings of dark despair – symbolic of anger and death.

Linked with PD’s anger were internalised images from his war experiences. It is not always helpful for trauma victims to recall their visual memories of scenes of horror, but for PD it was therapeutic – a release of explicit

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Figure 15.8 Anger (acrylic paint on paper).

memories, retained through internal images. He did a picture of one such memory – of a communal sculpture, created from the enemy’s dismembered body parts by his platoon and arranged into the shape of one person. This experience left feelings of suppressed guilt and shame. He was angry that he was exposed to such horror in the armed services. Negative self-concept is linked to anger, guilt and resentment. Figure 15.9, ‘Punish me’, was a self-portrait. For PD, the snake coming out of his mouth represented the fact that he was part of the killing. He explained how the battalion worked together – ‘so if someone up front gets to kill, then it is your kill. The snake is also a fearful thing – venomous things come out of my mouth – I’m saying “Punish me” – that’s what I need and want – I pick fights so that I get a hiding.’ At the bottom are ‘broken objects…The dead person represents that I could kill somebody. I’ve got a bad temper when I get stirred up – I’d see a murder in the paper and think I could have done that…and couldn’t remember.’

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Figure 15.9 Punish me (felt pen on paper).

Recovering from anger issues Figure 15.10, ‘Getting help’, is a symbolic reflection about PD’s therapy and the hope he feels in the transference. PD described the art work as follows: It’s about a person suffering and asking for help. The person is in the darkness, reaching out for help, looking for the depressive part I’m used to, I’m rebelling against what the help is telling me. The person in the darkness is me, with tears and blood. I did not think this day would come, that someone would understand that what I am suffering is a real thing. That’s why I went all these years, I didn’t think anyone would understand it. The positive there [indicates the hand] is still surrounded by darkness, but is reaching out for help, looking for the depressive part it is used to, [symbolised by the black hand reaching into yellow], but there’s still barriers. The yellow is ‘home base’, surrounded by what I know is depressive [black]. I can’t go back – but I can use the past to grow in a different direction. I’m using this [art] as a goal to get where I’m going.

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Figure 15.10 Getting help (acrylic paint on paper).

Symbolic resolution of anger Towards the end of therapy a personal symbol of ‘dragon’ began to emerge, although it was also evident before and during therapy. In later work, this metaphor became a symbol that led to self-healing. As an emerging symbol it could be traced back through the artwork and linked to expressions of anger and resentment. At the conclusion of therapy, independently of therapy sessions, PD completed a series of colourful, stylised dragons. They reflected a self-defining moment and contributed to the concluding process of therapy. Chetwynd (1982, p.125) comments on the symbol ‘dragon’ as having simultaneous ‘positive and negative attributes’ and that it ‘devours corpses and the light of conscious life’. Through the ‘dragon’ symbol, PD found a way to harness anger and self-destructive tendencies. Figure 15.11 is one of the dragons from the concluding dragon series.

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Figure 15.11 Dragon (from ‘Dragon Series’) (acrylic on canvas board).

At the same time PD also made progress in his personal life, as has already been outlined.

Transference and countertransference The art therapist can experience vicarious trauma as she listens to the client’s descriptions of horror, reproduced as visual memories through art-making. It is easy to react to the client’s symptoms of psychological pain, rather than sitting with and reflecting discomfort that needs to be held. It is crucial that the therapist is in regular clinical supervision so that the transference and countertransference is monitored, and boundaries are established and maintained. In the holding of the release of traumatic material, I had to accept that self-destructive tendencies continued alongside the process of art therapy. This challenged the therapeutic relationship, as well as questioning my therapeutic efficacy. The Australian public hostility described my own opposition to the Vietnam War. Throughout my teenage years at both secondary and, later, tertiary education I witnessed the imposition of compulsory conscription as young men avoided conscription by cutting off their trigger finger, ‘going bush’ or deciding to serve time in prison. As an Australian art college student,

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I had demonstrated my opposition in the anti-war movement. Forgotten personal issues about the political crisis of war resurfaced. These, and my ignorance about what Vietnam veterans had experienced and were still experiencing, had to be addressed in clinical supervision. The trauma of war personally confronted me. The countertransference also raised issues of professional isolation experienced when I first returned to Australia as a qualified art therapist. PD felt unappreciated for all that he had endured, so, too, my efforts to bring art therapy to Australia took a long time to be appreciated. There were parallels in our experience and in the countertransference, my own resentment surfaced. Like PD, I had felt regarded as some sort of ‘freak’ therapist. As my countertransference issues were processed, the transference of anger, guilt and blame could be held. In the processing of art work, it was important not to impose my own thoughts and feelings, but to stay with the presenting material. My responses were reflective of the client’s statements, as his thoughts, feelings and memories surfaced during and between therapy sessions. My task was to reaffirm and redefine this material, and to support my client while ‘not knowing’ and ‘not understanding’. At the time, I was completing analytic psychotherapy training and had opportunity to present verbatim case material in supervision. Peer supervision also took place with the counsellor from the Vietnam Veterans’ Counselling Service and the psychiatrist who was monitoring medication.

Conclusion Engagement with art-making in trauma healing provides opportunity for the client to become active in his recovery. After trauma, to be doing something towards self-recovery is more rewarding than self-inflicted social isolation and a sense of hopelessness. Art provides opportunity to express the unexpressed, to build on strengths, to state the unspoken and to search for an emerging identity. Crucial to recovery, identity shifts from victim to survivor of trauma. Although memory retrieval is important, recollection of trauma is not always a healing process. Through the creation of images and sculptural forms, visual memories are retrieved and associations are stimulated, but ‘distance from sensory imprints and trauma-related emotions’ is gained so that sensations and emotions can be observed and analysed (Van der Kolk 2003, p.187). Untreated, traumatic experiences and memories compound into pathologi-

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cal symptoms that psychologically debilitate war veterans from functioning effectively in the world (Yehuda, McFarlane and Shalev 1998). The reason art is significant in trauma recovery, might be to do with how memory functions in accessing ‘traumatic schema’ (Johnson 2000, p.305). Psychological trauma often results in emotional states that are unable to be translated into communicable language. Art therapy provides the visual language for the safe expression of negative, unacceptable emotions, such as anger, and holds promise in the reparation of trauma recovery.

References Bowlby, J. (1973) Attachment and Loss: Vol 2 Separation: Anxiety and Anger. New York, NY: Basic Books. Cited in R. Kobak (1999) ‘The emotional dynamics of disruptions in attachment relationships: Implications for theory, research, and clinical intervention.’ In J. Cassidy and P. R. Shaver (eds) Handbook of Attachment: Theory, Research and Clinical Applications. New York, NY: Guilford Press. Cathcart, M. (1993) Manning Clark’s History of Australia. Melbourne: Melbourne University Press. Chetwynd, T. (1982) Dictionary of Symbols. London: Paladin. Ganim, B. and Fox, S. (1999) Visual Journaling: Going Deeper Than Words. Wheaton, IL and Chennai (Madras), India: Quest Books, Theosophical Publishing House. Hieb, M. (2005) Inner Journeying Through Art-Journaling. London and Philadelphia, PA: Jessica Kingsley Publishers. Johnson, D. R. (2000) ‘Creative therapies.’ In E. B. Foa, T. M. Keane and M. J. Friedman (eds) Effective Treatments for PTSD: Practice Guidelines from the International Society for Traumatic Stress Studies. New York, NY and London: Guilford Press. Lusebrink, V. (1990) Imagery and Visual Expression in Therapy. New York, NY and London: Plenum Press. Menninger, K. A. (1938) Man Against Himself. New York, NY: Harcourt, Brace. Milia, D. (2000) Self-Mutilation and Art Therapy: Violent Creations. London and Philadelphia, PA: Jessica Kingsley Publishers. Miller, J. and Johnson, D. R. (1997) ‘Drama therapy in the treatment of combat-related post-traumatic stress disorder.’ The Arts in Psychotherapy 23, 383–395. Naumburg, M. (1987) Dynamically Oriented Art Therapy: Its Principles and Practice, second edition. Chicago, IL: Magnolia Street Publishers. Van der Kolk, B. A. (2003) ‘Posttraumatic stress disorder and the nature of trauma.’ In M. F. Solomon and D. J. Siegel (eds) Healing Trauma: Attachment, Mind, Body and Brain. New York, NY and London: WW Norton & Co. Yehuda, R., McFarlane, A. C. and Shalev, A. Y. (1998) ‘Predicting the development of post-traumatic stress disorder from the acute response to a traumatic event.’ Biological Psychiatry 44, 1305–1313.

Appendix Bibliography Books with chapters or sections on art therapy with anger: ·

Kaplan, F. (ed.) (2007) Art Therapy and Social Action. London: Jessica Kingsley Publishers.

·

Liebmann, M. (ed.) (1994) Art Therapy with Offenders. London: Jessica Kingsley Publishers.

·

Liebmann, M. (ed.) (1996) Arts Approaches to Conflict. London: Jessica Kingsley Publishers.

Articles (mostly from the USA) on research into art therapy with anger: ·

Kaplan, F. F. (1994) ‘The imagery and expression of anger: an initial study.’ Art Therapy: Journal of the American Art Therapy Association 11, 139–143.

·

Kaplan, F. F. (1998) ‘Anger imagery and age: further investigations in the art of anger.’ Art Therapy: Journal of the American Art Therapy Association 15, 116–119.

·

Phillips, H. (2004) ‘Re-thinking adolescent girls’ anger: an art-based approach to facilitating constructive expression.’ Unpublished Master’s degree thesis, School of the Art Institute of Chicago.

·

Silver, R. (ed.) (2005) Aggression and Depression Assessed Through Art: Using Draw-A-Story to Identify Children and Adolescents at Risk. New York, NY and Hove: Brunner–Routledge.

·

Smeijsters, H. and Cleven, G. (2006) ‘The treatment of aggression using arts therapies in forensic psychiatry: results of a qualitative inquiry.’ The Arts in Psychotherapy 33, 37–58.

Acknowledgement Thanks to Frances Kaplan for this section.

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List of Contributors Maggie Ambridge Maggie Ambridge qualified as an art therapist at Sheffield University in 1987. She has substantial experience of working both with abused children and with adults who suffered abuse in childhood. Following earlier employment with Social Services and the National Society for the Prevention of Cruelty to Children (NSPCC), she has worked for over 12 years, together with a colleague, psychologist Heather Bacon, to provide a specialist child protection project based in Northallerton NHS Child and Adolescent Mental Health Team. She has also previously written on subjects including art therapy and child abuse as well as the experience of adult survivors. Her own art work is an important aspect of both her professional and personal life.

Hilary Brosh After qualifying in 1991, Hilary Brosh worked in a variety of adult mental health settings in Leeds, and since 1999, she has worked in cancer care at the Robert Ogden Macmillan Centre in Leeds. She has been secretary and chair of the Odyssey Group, which promotes the value and use of the arts for mental health services in Leeds, and maintains her own studio practice.

Annette Coulter Annette is a UK-trained art psychotherapist with 30 years’ clinical experience, and is a registered practitioner in four countries, specialising in child, adolescent and family art therapy. Further training includes analytic group work, family therapy and child psychotherapy. She helped pioneer art therapy in Australia, working in mental health, community welfare and education. Currently, she co-ordinates the Upper Mountains Adolescent and Family Counselling Service in Katoomba, and provides private training, consultation and supervision through the Centre for Art Therapy Studies.

Terri Coyle Terri is a state-registered music therapist with over ten years’ experience of working therapeutically with offenders. During this time Terri has worked in the Prison Service, in an NHS psychiatric intensive care unit and a therapeutic community for personality-disordered offenders. Currently she works in an NHS medium-secure unit.

Hannah Godfrey Hannah Godfrey qualified as an art psychotherapist in 2002. Since then she has worked with both adult and adolescent clients through the National Probation Service and the Youth Offending Service. She works specifically with prolific and priority offenders

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within the community, based in Leicester and Rotherham. This covers a broad spectrum, including work with self-harm, addiction and personality disorders. Hannah is based in Sheffield. She is also a guest lecturer for Art Psychotherapy Post Graduate Training.

Camilla Hall Camilla Hall qualified as an art psychotherapist in 1987, having trained at Goldsmiths College, University of London. Since qualifying she has worked within the sphere of mental health, in particular with the manifestation of early trauma and abuse in the symptoms of eating disorders and self-harm. Camilla completed a master’s degree in art psychotherapy at Goldsmiths College in 2001. She is currently employed at the Olive Tree Personality Disorder Unit in Coventry.

Simon Hastilow Simon Hastilow has worked as a registered art therapist with offenders for the past 12 years, initially providing groups and individual work at HMP Lewes. He is currently employed as the professional lead for arts psychotherapies at an NHS medium-secure unit, overseeing the provision of arts psychotherapies for mentally ill offenders and people with personality disorders.

Susan Hogan Dr Susan Hogan is currently Reader in Cultural Studies and Art Therapy at the University of Derby. Her publications, as editor, include: Feminist Approaches to Art Therapy (1997, Routledge); Gender Issues in Art Therapy (2003, Jessica Kingsley Publishers), and, as sole author: Healing Arts: The History of Art Therapy (2001) with forewords by David Lomas (art historian) and Mary Douglas (anthropologist).

Elaine Holliday Elaine Holliday is a practising artist and art therapist with 20 years’ experience of working with children in foster care. Previously a senior manager in ISP (Integrated Services Programme), she continues to works as a principal therapist with children and young people in substitute family care. She is currently studying at the Tavistock Institute and developing her interest in systemic family therapy. She has recently worked in Thailand as a consultant art therapist.

Sheila Knight Sheila Knight graduated in fine art (sculpture) in 1984, going on to obtain her diploma in art therapy in 1985 and completing her MA in art psychotherapy at Sheffield University in 1995. Sheila worked as an art therapist from 1985, specialising in child, adolescent and family art therapy. In 1998, Sheila joined Bassetlaw Child and Family Therapy Service (Nottinghamshire Healthcare NHS Trust), where she practised as a clinical specialist in art psychotherapy until she died, in October 2006.

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Susan Law Susan Law was born and brought up in the Far East, with secondary and further education in Scotland. Her first nine-year career was as a social worker. She retrained as an art therapist and later in fine art. She has worked in art therapy for 23 years in local authority and private mental healthcare.

Marian Liebmann Marian Liebmann has worked in art therapy with offenders, with women’s groups and community groups, and, currently, in the Inner City Support and Recovery Team (adult mental health), where she has developed work on anger issues. She teaches and lectures on art therapy at several universities in the UK and Ireland. She also works in restorative justice, mediation and conflict resolution, and has run art and conflict workshops in many countries. She has written or edited ten books, including Art Therapy in Practice, Art Therapy with Offenders, Arts Approaches to Conflict, Art Therapy, Race and Culture, a second edition (2004) of Art Therapy for Groups, and most recently Restorative Justice: How It Works.

Leila Moules Leila Moules graduated from St Albans in 1983 with a postgraduate diploma in art psychotherapy, and has worked as an art therapist since then. She undertook group analytic training in 1997 and 2004. She has worked with elderly people, amputees, people with brain injuries, adults in mental health settings, adolescents with eating disorders, and at an adolescent forensic unit. For the past six years she has worked in the child and adolescent mental health service (CAMHS) in Crewe as art therapist and case manager.

Sue Pittam Sue Pittam first trained as a nurse and midwife. After having children, she taught young prisoners and realised that offending behaviour was not being adequately addressed. Qualifying in art psychotherapy, she increased her understanding of issues facing prisoners, with whom she has worked for 25 years. Sue has also used art therapy with adults and children through education and the health service. Having worked as an artist, art therapist and clinical supervisor, she has now retired.

Kate Rothwell A state registered art psychotherapist, supervisor and private practitioner, Kate has extensive experience in special needs, education and mental health settings with children and adults. Currently practising at Kneesworth House Hospital Medium Secure Unit, Kate also lectures on the MA Art Therapy programme at the University of Hertfordshire.

Sally Weston Sally Weston trained as an art therapist in 1990 after working as a teacher, community worker and in a collective making animated films. Her art therapy practice has been in adult mental health, and, since 1997, in neurological rehabilitation. She also works as a supervisor and in art therapy training.

Subject Index abuse see physical abuse; sexual abuse abused children 27–41 anger of 12, 27, 36 art therapy with case studies 27–39 role of 39–40 reduced ability to learn 90–1 acting out abused children 36–7, 40 aggression and violence as a result of 87 offending as a form of 105 in secure settings 119–20 adolescents mental health conditions 76 and self harm 72–83 adult mental health, CBT and art therapy in 166–79 aggression, function of 108 Aggression Replacement Training (ART) programme 11–12 aggressors, identification with 152–3 amygdala 90 ‘Androcles and the Lion’ 103–4, 108 Anger: The Misunderstood Emotion 11 anger of abused children 12, 27, 36 after brain injury 216–17

art therapy with see art therapy at pre-verbal stage 36 in cancer care 226–8, 233–6 and CBT see cognitive behavioural therapy chronic problems 12 combat survivors 242–3 as communication of distress 69–70 cultural element 11 and danger 74–7 vignettes 77–83 different views of 10–12 different ways of working with 12–13 expressing see expressing anger metaphors for 17, 159, 228–9, 236 neurophysiology 90 and offending 104–5 and physical abuse 96–9 positive aspect 12, 74–5 in a secure setting 118–20 and sexual abuse 93–6 symbolic expression 17 symbolic resolution 245, 253–4 unresolved 103–4 verbalisation of 227–8 women and self-harm 151–65 young male offenders 87, 91 anger diary 47–9 anger management folder 47–53

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anger management groups 9–10 anger management manuals 11 anger management programmes cognitively-based 216 elements for successful 11 anger management toolbox 46–57 anger rating scale 48, 49–51 angry mothers 197–210 art therapy support groups 197 becoming a mother 198–9 bad birth experiences 199–201 breastfeeding 207–9 exhaustion and dismal aspects of motherhood 204–6 power and control 201–4 vulnerability and lack of support 206–7 angry words 53 arson drinking and disinhibition 138 as an expression of dissatisfaction with environmental changes 136 as a means of suicide 141 and self-harm 137–8 arsonists common educational features 135 treating 146

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art media 16 art therapy, with anger 13–16 abused children case stories 27–39 role of 39–40 adolescents and self-harm, case studies 77–83 in adult mental health session 1: making a picture of anger 168–70 session 2: childhood memories 170–1 session 3: a difficult relationship 171–4 session 4: self-box part I 174 session 5: self-box part II 175, 176 session 6: loss and change 176–7 session 7: regret and forgiveness 178 session 8, change through learning 178–9 after brain injury 211–12 anger, confidentiality and risk issues 224 case study 217–23 early rehabilitation 223–4 role of 215 art media 16 assessment see assessment cancer care 226, 228–9, 237 case studies 229–33 and CBT see cognitive behavioural therapy with a deaf client 180–94 case study 184–93 setting 180–1

ART THERAPY AND ANGER

theme-based model 183–4 different ways of using 16–18 directive and non-directive methods 16 diversity issues 15 in forensic settings female remand prison 120–5 mental health medium-secure unit 125–32 with foster children 58–9 case study 59–70 gender issues 15–16 mothers 197–210 multidisciplinary work 15, 78 prolific and priority offenders anger in assessment 107–8 depiction of ideal parenting 110–11 expressing anger passively 109–10 paradox of anger 106 parallel with Androcles and the lion 103–4, 108 use of masks 111–15 testing out dangerous thoughts and wishes 120 Vietnam war veteran 238 anger issues 242–3 anger and resentment series 247–52 expression of anger in early work 245–7 processes 244–5 recovery from anger issues 252, 253 referral 239–41 role of art media 241–2

symbolic resolution of anger 253–4 transference and countertransference 254–5 visual diary 243–4 women who self-harm 153–64 young male offenders 87, 88–90, 100–1 case studies 93–9 self-evaluation form 91–3 see also music and art therapy art therapy support groups 197 artwork, haptic, spontaneous qualities in 245 Asperger’s syndrome, use of sketch book with 47 assessment of children 43, 45 session, with female offender 122–3 see also risk assessment attachment loss of 87–9 and mentalisation 153 see also good attachment autobiographical memory 37 ‘baby blues’ 201 basic relaxation technique 51–2 bereavement 100, 198, 234, 236 Billy 27–32, 39–40 Bion, Wilfred 45 birth plans 200 blue and black breathing image 53–5 body outline drawing 55–7 brain injury anger after 216–17 art therapy after 211–12

SUBJECT INDEX

anger, confidentiality and risk issues 224 case study 217–23 early rehabilitation 223–4 role of 215 causes of acquired 212–13 emotional needs in rehabilitation 214–15 emotional and psychological issues after 214 neuro–rehabilitation services 213 survival rates 212 breastfeeding 207–9 breathing techniques 51–3

working with families 44–5 see also abused children; foster children cognitive behavioural therapy in adult mental health 166–79 action skills, being assertive, handling aggressive criticism 176–7 blocks used to prevent awareness of anger 168–70 choosing realistic personal rules 170–1 goals 166 inpatients 167 perceiving provocations differently 171–4 cancer care referrals 167 anger in 226–8, 233–6 relaxing, managing art therapy in 226, stress/anger and 228–9, 237 self-talk 178–9 case studies 229–33 using coping self-talk cancer stories 228 174 catharsis 16–17 using visualising 175 CBT see cognitive anger management behavioural therapy groups 9–10 change with a deaf client loss and 176–7 180–94 through learning 178–9 case study 184–93 Child and Adolescent setting 180–1 Mental Health Service community orders 103 anger management with concrete objects 119 children and young confidentiality 223–4 people 42–57 containment 61, 91, 100, work with abused 119–32, 236 children 27–41 continuing assessment child-management styles process 45 50 coping mechanisms 31, childbirth experiences, 163 bad 199–201 coping self-talk 174 childhood memories, countertransference 162, exploring 170–1 254–5 children, anger management Creative Response, The with 42–57 226 reluctant participants 45 toolbox 46–57

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creativity, replacing anger by 18 Dan 93–6 danger, anger and 74–7 vignettes 77–83 deaf client, CBT and art therapy with 180–94 case study 184–93 setting 180–1 deaf culture 181 defence mechanisms distancing 79, 138–9 ‘fight or flight’ response 43, 50, 79–80 identification with aggressors 152–3 letting down 142 self-destructing behaviour 119 delinquency 119 deprivation 12, 87, 135 difficult relationships, expressing 171–4 directive therapy methods 16 disinhibition, and arson 138 displaced anger 233, 234, 235 dissociation 31, 245 distancing 79, 138–9 distress, anger as communication of 69–70 diversity issues 15 dragon symbol, resolution of anger 253–4 drinking and arson 138 and feelings 143 Eliza 33–4, 40 emotional development 90 emotional issues, after brain injury 214 emotional needs, brain injury rehabilitation 214–15

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endocrine changes, after childbirth 200–1 exercises to control anger 18 to look at anger 18 exhaustion, angry mothers 204–6 expressing anger in art work 245–7 at pre-verbal stage 36 passively 109–10 self-sabotage as a form of 105–6 in a symbolic way 17 use of masks 111–15 expressing feelings behind anger 18 that mask anger 17 through films, games and humour 221–2 Expressive Therapies Continuum 242 externalisation 27, 39, 138

case study 59–70 fragmented consciousness 245 free association 243 ‘free floating’ anger 233, 234, 235

families, working with 44–5 family art therapy 76 feelings bringing into artwork 139–40 dealing with negative 228–9 and drinking 143 naming 50–1 projection on to others 139, 235 split-off 98, 113 see also expressing feelings female remand prison, art therapy in 120–5 ‘fight or flight’ response 43, 50, 79–80 forgiveness 178 forensic settings, working in 117–32 Foster Care Associates (FCA) 58 foster children 58–71 art therapy with 58–9

gender issues 15–16 gender split, in offending 104 good attachment 99 guided fantasy 53 guilt of angry mothers 197, 201, 203 and negative self-concept 251 of parents 42 haptic quality, in artwork 245 Heather 122–5, 132 hippocampus 90 holding 119, 132

James and his father (Mr X) 81–3 Jamie 35–9, 40 Jane 77–9 Jason 109–15 Joan 79 Jules 79–81 justified anger 233, 234 ‘K’ activity 45 Karl 59–70 Liam 54–5 limbic centre 90 loss anger through 87–8, 96, 198, 227 and change 176–7 writing about fear and pain of 235

Mark 184–93 masks, use of to express anger 111–15 maternity leave, returning identification, with from 198–9 aggressors 152–3 Maureen 153–8, 165 identity 38, 175, 255 medical interventions, image-making, during childbirth 200 containment of anger medium secure settings 236 art therapy in 125–32 images, repetition of, in music and art therapy in therapies 112 134–46 individual work, with memory young offenders 89 retrieval, trauma 255 infant–mother relationship see also autobiographical 45, 119 memory; childhood infantile anger 36 memories inhibited grief 198 mental health insight 43, 47, 193 conditions, in Integrated Services adolescence 76 see also adult mental Programme (ISP) 58 health ‘interconnected cogs’ mental health metaphor 159 medium-secure unit, intermediate space 120 art therapy in 125–32 internalisation 27, 40, 99, mentalisation 153 153 metaphors, for anger 17, introjection 164 159

SUBJECT INDEX

military metaphors, used to fight cancer 228–9, 236 morality 152–3 motherhood discovering the reality of 206 see also infant–mother relationship multidisciplinary work 15, 70 music and art therapy, in a medium secure setting 134–46 client and context 134–6 learning from experience 146 therapists, team and family parallels 145 work done before decision to transfer 136–9 work done after decision to transfer 139–45

young male offenders offending acting out as a form of 105 and anger 104–5 Oppositional Defiance Disorder 43 orbitofrontal area, of the brain 90

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acting out 105 anger and offending 104–5 art therapy with anger in assessment 107–8 case study 109–15 paradox of anger in 106 parallel with ‘Androcles and the Lion’ 103–4, 108 parent–child therapy 76 client group 102–3 parental aggression 100 defined 102 parental separation 99 function of aggression parenting, depiction of 108 ideal 110–11 self-sabotage as a form parents of expressing anger attitudes, importance of 105–6 44 psychological issues, after child-management styles brain injury 214 50 psychological self-repair guilt 42 228, 235 unrealistic expectations psychological trauma of therapy 42 90–1 working with non-abusive 35 see also angry mothers radiotherapy, anger after Nathan 217–23 peer group pressure 76 227 negative feelings, dealing Philip 125–32 recovery with 228–9 physical abuse from anger issues 252, negative self-concept 251 and anger 96–9 253 neuro-rehabilitation see also abused children from trauma 255–6 services 213 play, art therapy with 30 as a new danger 124 neurophysiology 90 Playing with Fire 183 regret 178 non-abusive parents, post-natal depression 201, relationships working with 35 206 and angry mothers non-directive therapy post-traumatic stress 206–7 methods 16 disorder see also difficult non-traumatic brain art therapy with relationships; injuries 212–13 238–56 infant–mother non-verbal medium, use of neurophysiology 90 relationship 136–7 power and control, angry relaxation techniques mothers 201–3 51–3, 184 pre-verbal stage, anger at relief, in sharing offenders 36 experiences 171 working with, in pregnancy, art therapy reluctant participants 45 forensic settings during 201 reparative function, anger 117–32 probation licences 103 as 236 see also prolific and projection 139, 235 resentment, expressing in priority offenders; prolific and priority artwork 247–52 violent offenders; offenders 102–15 resistance 124

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risk assessment adolescents and self–harm 75 in art therapy 15 prolific and priority offenders 106, 107–8 risk issues, therapy with brain-injured clients 224 Robert Ogden Centre 226, 228

sketch book 46–7 social skills training 146 split-off feelings 98, 113 splitting 31, 41, 51, 112 spontaneity, in artwork 245 staircase (anger rating scale) 49–50 Steven 107–8 suicidal thoughts, self-harm and 141–2 support, lack of, angry mothers 206–7 suppressed anger 234, 236 symbolic expression, of anger 17 symbolic resolution, of anger 245, 253–4 symbols, repetition of, in therapies 112

Samantha 158–64, 165 scapegoat transference 114–15 Sean 96–9 secure attachment 153 secure setting, anger in 118–20 self-box 174, 175, 176 self-concept, negative 251 self-destructive behaviour 119 self-esteem, poor 12 self-harm abused children 40 adolescents 72–83 art therapy with women who self-harm 153–64 definitions 152 link between arson and 137–8 and suicidal thoughts 141–2 to express anger in artwork 245, 246 self-neglect 152 self-sabotage, as a form of expressing anger 105–6 self-talk 174 sexual abuse and anger 93–6 short-term therapy 91 young offenders’ experience of 100 see also abused children short-term therapy 91 Simon 55–7

recovery from anger issues 252, 253 referral 239–41 role of art media 241–2 symbolic resolution of anger 253–4 transference and countertransferenc e 254–5 visual diary 243–4 violent offenders, anger management groups 9 visual diary 243–4 visual metaphors 17, 73–4 visualisation 53–5, 175 vulnerability, angry mothers 206–7

war veteran see Vietnam war veteran women therapeutic boundaries 91, anger and self-harm 100 151–65 therapeutic space 45, 91, see also angry mothers 120 ‘women only’ anger Toby 134–46 management groups transference 114–15, 252, 10 254–5 trauma see brain injury; young male offenders post-traumatic stress 87–101 disorder; psychological anger of 87, 91 trauma art therapy with 87, traumatic life events 100 88–90, 100–1 case studies 93–9 neurophysiology 90 ‘unacceptable wish’ facing self-evaluation form significance of 112 91–3 outside social factors verbalisation, of anger 99–100 227–8 young people see Vietnam War 238–9 adolescents; children Vietnam war veteran 238–56 art therapy with 238 anger issues 242–3 anger and resentment series 247–52 expression of anger in early work 245–7 processes 244–5

Author Index Ambridge, M. 35 Barraclough, J. 227, 233, 234 Bateman, A. 153 BBC 87 Black, L. 11, 182 Blaffer Hrdy, S. 197 Bowlby, J. 99, 119, 242 Bristol Centre for Deaf People 181 British Society of Rehabilitation Medicine (BSRM)) 214 Cairns, K. 98, 99 Cathcart, M. 239 Chetwynd, T. 253 Connell, C. 226, 229 Coote, J. 229 Dalai Lama 50 Delshadian, S. 135, 138 Dickinson, E. 77, 83 Dreifuss-Kattan, E. 227, 228, 235, 236 Dryden, W. 12 Faulkner, A. 227 Favazza, A.R. 152 Fine, M. 182, 189 Fisher, M. 12 Fonagy, P. 153 Fox, S. 243 Freud, A. 152, 164 Freud, S. 119 Ganim, G. 243 Garner, R.L. 215, 216 Geller, J.L. 138

Gerhardt, S. 12, 90 Gibbs, L. 103 Glass, C. 136 Glick, B. 12 Goldstein, A. 12 Goleman, D. 90 Hanh, T.N. 12 Hewitt, S.K. 37 Hickey, D. 197 Hieb, M. 243 Higgins, L. 182 Hills, J. 70 Hogan, S. 199, 200 Hoggard, M. 182 Hollin, C. 99 Hope, S. 136 Howells, K. 99 Huet, V. 182 Jackson, H.F. 136 Johnson, D.R. 239, 242, 256 Johnstone, B. 213 Johnstone, M. 104 Kaplan, F. 14 Kitson, N. 182 Kitzinger, S. 200 Klein, H. 182 Kübler-Ross, E. 198

Macbeth, F. 182, 189 McDonald, K. 52 McFarlane, A.C. 256 McGraw, M. 215 Malcolm, R. 45 Martin, E. 209 Meltzer, H. 72 Menninger, K.A. 245 Mental Health Foundation 72 Milia, D. 245 Miller, J. 239, 242 National Institute of Clinical Excellence (NICE) 72 Naumburg, M. 244 Nelson-Jones, R. 167 Novaco, R.W. 11, 182 Oakley, A. 197 O’Rourke, S. 182 Perera, S.B. 114 Pratt, M. 226 Prigatano, G.P. 215 Pudney, W. 12 Rabiger, S. 132 Rajan, L. 197 Ramm, M. 11, 182 Raphael, B. 198 Repo, E. 141 Rich, A. 207 Rose, M.J. 213, 216 Rosen, P. 152 Rycroft, C. 105

Laatsch, L. 216 Ladd, P. 181 Lee, C. 102 Lerner, H. 12 Levens, M. 120, 124 Liebmann, M. 14, 55, 184 Lusebrink, V. 242, 245 Sandström, C.I. 44 Luzzatto, P. 228 Sano, M. 216

267

268

Schavieren, J. 106, 112, 114 Schore, A. 90 Shalev, A.Y. 256 Short, J. 135, 138 Smith, J. 135, 138 Sontag, S. 228, 236 Stewart, L.A. 146 Stonnington, H. 213 Sury, R.W. 216 Swan-Foster, N. 201 Tavris, C. 11, 12, 15 Teasdale, C. 118 Thomas, G. 229 Turner, J. 182 Turp, M. 152 Van der Kolk, B.A. 239, 255 Wald, J. 215 Walsh, B.W. 152 Whitehouse, E. 12 Wildgoose, K. 102 Williams-Saunders, J. 119 Winnicott, D.W. 106, 112, 119 Wisdom, C. 215 Wood, M. 226 World Health Organization (WHO) 43 Worrall, A. 104 Yehuda, R. 256 Zulueta, F. de 87, 96, 98, 99

ART THERAPY AND ANGER

Figure 3.3 King Kong.

Figure 4.2 Jules: Pattern.

Figure 5.2 Dan: Stormy sea.

Figure 5.3 Dan: Buildings on fire.

Figure 7.2 Philip: Self-portrait as a devil.

Figure 7.5 Philip: Swastika.

Figure 7.6 Philip: Landscape.

Figure 8.1 Toby: Picture 1.

Figure 9.1 Maureen: Moving towards the light.

Figure 9.3 Sam: The bomb.

Figure 9.4 Coffin with boxing gloves.

Figure 15.1 Vietnam. (Cardboard, felt pen, biro, acrylic paint) (Reproduced with permission of the National Vietnam Veterans Museum, Phillip Island, Victoria, Australia.)

Figure 15.4 Insignificance magnified (acrylic paint on paper).

Figure 15.6 Vitality (acrylic paint on paper).

Figure 15.10 Getting help (acrylic paint on paper).

Figure 15.11 Dragon (from ‘Dragon Series’) (acrylic on canvas board).